Management of recurrent symptoms after per-oral endoscopic myotomy in achalasia

doi:10.1016/j.gie.2017.04.036

Gastrointestinal Endoscopy

Volume 87, Issue 1, January 2018, Pages 95-101

https://doi.org/10.1016/j.gie.2017.04.036 Get rights and content

Background and Aims

Per-oral endoscopic myotomy (POEM) has been rapidly gaining ground as a treatment for achalasia. Although POEM is a safe and effective treatment, a subset of patients has persistent or recurrent symptoms after POEM. This study aimed to examine the efficacy of different retreatments after failed POEM.

Methods

POEM was performed on 441 patients with achalasia at 3 tertiary-care hospitals between 2010 and 2015. A review of prospectively collected data was conducted. All patients with achalasia with significant persistent or recurrent symptoms within 3 years after POEM, defined as an Eckardt symptom score >3, were included.

Results

Forty-three of 441 patients (9.8%) had persistent or recurrent symptoms after POEM, of which 34 (8%) received 1 or more retreatments. Retreatment with laparoscopic Heller myotomy and retreatment with POEM showed a modest efficacy of 45% and 63%, respectively, whereas pneumatic dilatation showed a poor efficacy of only 0% to 20%, depending on the size of the balloon. Male patients were more likely to have retreatment failure than female patients (P = .038).

Conclusions

In patients with achalasia with persistent or recurrent symptoms after failed POEM, retreatment with laparoscopic Heller myotomy or retreatment with POEM has a higher efficacy than retreatment with pneumatic dilatations. Failure of retreatment occurred more often in male patients.

Section snippets

Study participants

All patients with achalasia with recurrent or persistent symptoms at any moment after POEM were identified in 3 tertiary-care hospitals between 2010 and 2015. The hospitals are in the United States, The Netherlands, and Germany. These 3 hospitals have been performing POEM for over 4 years in randomized controlled trials, and all patients are treated according to standard protocols and their cases are entered into prospective databases.⁴ All patients were included in randomized controlled

Patient characteristics

From a cohort of 441 patients who underwent POEM, excluding technically failed procedures, we identified 43 patients (9.8%, 14 female) with achalasia and an Eckardt score of >3 at any moment after POEM. Twenty-four patients were included in Germany, 10 patients in The Netherlands, and 9 patients in the United States. All POEMs were performed between August 2010 and January 2015, and follow-up was recorded until August 2015. In Table 1, we summarized patient characteristics and diagnostic

Discussion

Although many reports show that POEM is a very effective treatment for achalasia, treatment failure does occur. We describe the management of patients with achalasia with recurrent or persistent achalasia symptoms after POEM. In our cohort, LHM and repeat treatment with POEM showed a moderate efficacy after POEM failure, whereas pneumodilatation showed a rather poor efficacy. After failure on 35-mm diameter pneumodilatation, 40-mm diameter balloon dilatations were not effective either. The

References (34)

J.A. Ortega et al.
Endoscopic myotomy in the treatment of achalasia
Gastrointest Endosc
(1980)
K. Sumiyama et al.
Submucosal endoscopy with mucosal flap safety valve
Gastrointest Endosc
(2007)
V.F. Eckardt
Clinical presentations and complications of achalasia
Gastrointest Endosc Clin N Am
(2001)
J.E. Pandolfino et al.
Achalasia: a new clinically relevant classification by high-resolution manometry
Gastroenterology
(2008)
A. Tyberg et al.
A multicenter international registry of redo per-oral endoscopic myotomy (POEM) after failed POEM
Gastrointest Endosc
(2017)
M. Onimaru et al.
Peroral endoscopic myotomy is a viable option for failed surgical esophagocardiomyotomy instead of redo surgical Heller myotomy: a single center prospective study
J Am Coll Surg
(2013)
Y. Vigneswaran et al.
Peroral endoscopic myotomy (POEM): feasible as reoperation following Heller myotomy
J Gastrointest Surg
(2014)
K. Farhoomand et al.
Predictors of outcome of pneumatic dilation in achalasia
Clin Gastroenterol Hepatol
(2004)
J.E. Pandolfino et al.
Achalasia: a systematic review
JAMA
(2015)
U.C. Ghoshal et al.
Pathogenesis of achalasia cardia
World J Gastroenterol
(2012)

G.M. Campos et al.

Endoscopic and surgical treatments for achalasia: a systematic review and meta-analysis

Ann Surg

(2009)

H. Inoue et al.

Peroral endoscopic myotomy (POEM) for esophageal achalasia

Endoscopy

(2010)

V. Kumbhari et al.

Peroral endoscopic myotomy

World J Gastrointest Endosc

(2015)

P.J. Pasricha et al.

Submucosal endoscopic esophageal myotomy: a novel experimental approach for the treatment of achalasia

Endoscopy

(2007)

S.B. Orenstein et al.

Peroral endoscopic myotomy (POEM) leads to similar results in patients with and without prior endoscopic or surgical therapy

Surg Endosc

(2015)

D. Von Renteln et al.

Peroral endoscopic myotomy for the treatment of achalasia: an international prospective multicenter study

Gastroenterology

(2013)

Werner YB, Costamagna G, Swanstrom LL, et al. Clinical response to peroral endoscopic myotomy in patients with...

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Pneumatic dilation for achalasia in the “POEM era”: Still a valuable ally
2024, Digestive and Liver Disease
Endoscopic treatments such as peroral endoscopic myotomy (POEM) and pneumatic dilation (PD) are commonly used to treat achalasia. Although POEM has gained popularity due to its high efficacy, the technique is more complex and may be associated with a higher risk of long-term complications compared to PD. This narrative review will focus on efficacy and safety of PD and POEM, and their suitability for different patient populations. While evidence suggests that POEM may be preferred for type III achalasia, PD remains a valuable alternative for patients with a straight, non-dilated esophagus, who prioritize the preservation of anatomical integrity and a lower risk of post-procedural gastroesophageal reflux disease (GERD). While PD carries a non negligibile risk of perforation, it has an excellent safety profile in terms of GERD and is minimally likely to cause permanent esophageal deformation. PD can be repeated with minimal risks to maintain symptom relief, whereas reversing permanent anatomical modifications related to POEM is difficult. The choice of treatment for achalasia should be patient-tailored, considering benefits and drawbacks of each intervention. The importance of personalized approach in the "POEM era" is highlighted, emphasizing the reasons why PD should still be considered a valuable option in the therapeutic armamentarium for achalasia. Areas requiring further research will be also outlined.
Complications related to third space endoscopic procedures
2024, Best Practice and Research: Clinical Gastroenterology
Third space endoscopy (TSE) encompasses a breadth of procedures for the treatment of a variety of GI disorders. The widespread use of per-oral endoscopic myotomy (POEM) and its diversification to include extended indications and at locations other than the oesophagus has provided an insight into the potential complications encountered. The most common adverse events associated with POEM, the epitome of TSE procedures, include insufflation related injuries, bleeding, failure of mucosal barrier, infections, pain, blown out myotomy and gastroesophageal reflux disease. The purpose of this review is to highlight the pitfalls and to identify the risk factors that may lead to adverse events, and to recommend appropriate salvage interventions in the scope of the current evidence.
Role of functional luminal imaging probe in the management of postmyotomy clinical failure
2022, Gastrointestinal Endoscopy
Citation Excerpt :
Therefore, in this study, we hypothesized that combining the 2 parameters, DI from FLIP and IRP from HRM, in evaluating patients with clinical failure after a prior myotomy will aid in selecting candidates who might benefit more from LES-directed retreatment. The literature on the best management approach in this setting remains limited to relatively small case series,29-31 with only 2 retrospective studies comparing the different management approaches.24,32 The reported heterogeneous rates of clinical success after repeat POEM range from 63% to 100%,24 further emphasizing the significance of choosing the right candidates to benefit from repeated LES-directed therapies such as POEM or PD.
A small percentage of patients with esophageal dysmotility disorders (EDDs) fail to improve or relapse after management by laparoscopic Heller myotomy (LHM) and peroral endoscopic myotomy (POEM). In this study, we aimed to describe the role of functional luminal imaging probe (FLIP) in identifying patients who might benefit from lower esophageal sphincter (LES)-directed retreatment.
This was a retrospective study at 6 tertiary care centers (United States, 4; Europe, 1; Asia, 1) between January 2015 and April 2021 involving patients with prior failed myotomy. The primary outcome was the impact of the use of FLIP on the management of patients with prior failed myotomy.
One hundred twenty-three patients (62 women [50%]; mean age, 53 ± 21.1 years) who underwent LHM (n = 53, 43%) or POEM (n = 70, 57%) for the management of achalasia (n = 98) or other EDDs (n = 25) had clinical failure at a median time of 10.8 months (interquartile range, .8-17.3) postprocedure. Twenty-nine patients had apposing “abnormal” diagnoses in terms of integrated relaxation pressure (IRP) >15 mm Hg on HRM and distensibility index (DI) <2.8 mm²/mm Hg on FLIP, with ultimate change in management noted in 15 patients (10 directed toward conservative management, 5 directed toward LES-directed retreatment). The impact of FLIP on both diagnosis and management was noted in 15 of 29 patients (52%). In the subgroup analysis of 44 patients who underwent LES-directed retreatment, clinical success was highest among patients with both abnormal IRP and DI (21/25 [84%]) versus patients with only abnormal IRP (8/14 [57%]) or only abnormal DI (3/5 [60%], P = .04), with DI at 40-mL distension volume on FLIP identified as an independent predictor of clinical success (odd ratio, 1.51; 95% confidence interval, 1.02-2.1; P = .03).
The finding of this study further suggests the important role of using FLIP in addition to HRM in evaluating patients with clinical failure postmyotomy.
Blown-out myotomy: an adverse event of laparoscopic Heller myotomy and peroral endoscopic myotomy for achalasia
2021, Gastrointestinal Endoscopy
Citation Excerpt :
The current treatment modalities for disrupting the LES are extremely effective. However, failure of treatment or recurrence of symptoms can occur in 10% to 20% of patients undergoing myotomy and 10% to 30% of patients undergoing pneumatic dilation.2-4 The presumed mechanisms of failure are incomplete myotomy or ineffective disruption of the LES.5,6
Although laparoscopic Heller myotomy (LHM) or peroral endoscopic myotomy (POEM) is highly effective, 10% to 20% of patients with achalasia remain symptomatic after treatment. In evaluating such patients, we have observed a pattern of failure associated with a pseudodiverticulum, or blown-out myotomy (BOM), in the distal esophagus. We aimed to assess risk factors and patient-reported outcomes associated with a BOM.
We reviewed our manometry database for patients with achalasia previously treated with LHM or POEM. We included patients who had a post-treatment esophagram within 1 year of their follow-up manometry. A BOM was defined radiographically as a wide-mouthed outpouching (>50% increase in esophageal diameter) in the area of the myotomy.
One hundred twenty-nine patients with achalasia who underwent treatment were included; 23 (17.8%) had a BOM. Comparing patients with a BOM with those without, post-treatment Eckardt scores were significantly greater (5 vs 2, P = .002), type III achalasia was more common (39.1% vs 14.2%, P = .005), and LHM was more common than POEM (73.9% vs 26.1%, P = .013). The integrated relaxation pressure was also significantly greater in the BOM group (15.0 mm Hg vs 11.0 mm Hg, P = .025).
BOM is a common adverse event after myotomy for achalasia but is not seen after pneumatic dilation. Pretreatment type III achalasia, LHM as opposed to POEM, and a greater post-treatment integrated relaxation pressure were risk factors for developing a BOM. We speculate that esophageal wall strain in the area weakened by myotomy, whether from residual spastic contractility or continued esophageal outflow obstruction, may be the underlying mechanism of BOM development.
Development of a preoperative risk-scoring system for predicting poor responders to peroral endoscopic myotomy
2021, Gastrointestinal Endoscopy
Citation Excerpt :
Peroral endoscopic myotomy (POEM) is a highly safe and clinically effective treatment for EMD with short-term follow-up2; however, several prospective multicenter studies have shown that treatment of approximately 10% of patients who undergo POEM eventually fails 1 to 2 years after POEM.3,4 Furthermore, some patients with significant recurrent or persistent symptoms after POEM need retreatments within 3 years.5 Some studies have suggested that risk factors for POEM failure include disease duration, previous treatments, and preoperative Eckardt score, among others;6-8 however, they were not validated and predicted a degree of risk.
Peroral endoscopic myotomy (POEM) is an effective treatment for esophageal motility disorder. However, some people are poor responders who will probably need retreatments, such as endoscopic pneumatic dilation or re-POEM, and a scoring system for the prediction of poor responders preoperatively has not yet been established. We aimed to develop and validate a preoperative scoring system for predicting poor responders.
Overall, 244 patients who underwent POEM for esophageal motility disorders in our hospital from April 2015 to March 2019 were retrospectively included in this study. Poor responders were defined as patients with any of following: (1) Eckardt score ≥3 at 1-year follow-up, (2) endoscopic findings of food retention at 1-year follow-up, and (3) retreatments within 1 year after POEM. A risk-scoring system for poor responders was developed based on multiple logistic regression analysis, and its performance was internally validated using bootstrapping.
Forty patients were diagnosed as poor responders at the 1-year follow-up. In the multivariate study, points for risk scores were assigned for 4 independent risk factors as follows: pretreatment Eckardt score (1-point increments), previous treatments (4 points), sigmoid-type esophagus (4 points), and esophageal dilation grade ≥II (4 points). The scoring system could predict an estimated risk for poor responders and provided satisfactory discrimination (area under the receiver operating characteristic curve, 0.78; 95% confidence interval, 0.68-0.88) and calibration (slope = 0.93; 95% confidence interval, 0.62-1.31).
A validated risk-scoring system for predicting poor responders preoperatively was established; this system could be useful for selecting treatment strategies and postoperative surveillance.
Treating children with achalasia using per-oral endoscopic myotomy (POEM): Twenty-one cases in review
2020, Journal of Pediatric Surgery
Citation Excerpt :
This is a rate similar to that seen in the literature for adult and pediatric patients [7,9]. While two-thirds of our patients required re-intervention (most commonly dilation) for recurrent symptoms, only 3 required a repeat myotomy; these rates are similar to rates seen in an adult population undergoing POEM [11]. Of note, literature reviewing the use of thoracoscopic esophagomyotomy in children suggests a 15%–26% need for reintervention/dilation; however, this study had higher reflux rates and was limited by lack of objective symptom scoring to determine the need for reintervention [12].
Per-oral endoscopic myotomy (POEM), a modern treatment for achalasia, has only recently emerged as an option for pediatric patients. Here we describe and characterize the success of POEM in children with achalasia.
A single-institution prospective cohort study was performed of patients < 18 years old who underwent POEM from 2014 to 2019. Main outcomes were success at one year (Eckardt ≤ 3), procedure duration, complications, reintervention.
The median age of patients (n = 21) was 13 years (range 2–17). Median procedure duration was 92 min (range 52–259) with case duration plateau of 87.4 min and learning rate of 15.5 cases. Intraoperative complications included capnoperitoneum requiring needle decompression and mucosotomy requiring additional clips. One patient experienced chest pain with small capnoperitoneum seen on chest radiography, and three patients had extraluminal carbon dioxide found incidentally on routine radiography. All were managed with observation. Pre- versus 1-month postprocedure Eckardt scores were significantly improved (7 ± 2 versus 1 ± 2, p < 0.0001, and median ± SD) with 100% symptomatic relief at one year. To achieve this, 13 patients required further dilation(s), one required laparoscopic Heller myotomy, and two required repeat POEM.
POEM is a viable and safe treatment for pediatric patients with achalasia. We demonstrate improvement in symptoms and procedure proficiency with minimal intra- and postoperative complications.
Prospective cohort study.
Level II.

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: DISCLOSURE: A. Bredenoord received research funding from Endostim, Medical Measurement Systems, Danone, and Given and received speaker and/or consulting fees from MMS, Astellas, AstraZeneca, and Almirall. J. Pandolfino received funding from Ironwood (consulting), Medtronic (consulting, speaking), and Sandhill (consulting, speaking). P. Fockens received consulting fees from Medtronic, Fujifilm, and Olympus and a fee for speaking from Cook. All other authors disclosed no financial relationships relevant to this publication.

: See CME section; p. 272.

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Original articleClinical endoscopyManagement of recurrent symptoms after per-oral endoscopic myotomy in achalasia

Background and Aims

Methods

Results

Conclusions

Section snippets

Study participants

Patient characteristics

Discussion

Gastrointest Endosc

Gastrointest Endosc

Gastrointest Endosc Clin N Am

Gastroenterology

Gastrointest Endosc

J Am Coll Surg

J Gastrointest Surg

Clin Gastroenterol Hepatol

Achalasia: a systematic review

JAMA

Pathogenesis of achalasia cardia

World J Gastroenterol

Endoscopic and surgical treatments for achalasia: a systematic review and meta-analysis

Ann Surg

Peroral endoscopic myotomy (POEM) for esophageal achalasia

Endoscopy

Peroral endoscopic myotomy

World J Gastrointest Endosc

Submucosal endoscopic esophageal myotomy: a novel experimental approach for the treatment of achalasia

Endoscopy

Peroral endoscopic myotomy (POEM) leads to similar results in patients with and without prior endoscopic or surgical therapy

Surg Endosc

Peroral endoscopic myotomy for the treatment of achalasia: an international prospective multicenter study

Gastroenterology

Original article
Clinical endoscopy
Management of recurrent symptoms after per-oral endoscopic myotomy in achalasia