Per-oral endoscopic myotomy in patients with or without prior Heller myotomy: comparing long-term outcomes in a large U.S. single-center cohort (with videos).Zhang X, Modayil RJ, Friedel D, Gurram KC, Brathwaite CE, Taylor SI, Kollarus MM, Modayil S, Halwan B, Grendell JH, Stavropoulos SN. Gastrointest Endosc. 2017 Nov 6. [Epub ahead of print]

BACKGROUND AND AIMS: Heller myotomy (HM) is one of the most effective treatments for esophageal achalasia. However, failures do exist and the success rate tends to decrease with time. The efficacy of rescue treatments for patients with failed Heller is limited.

A few small-scale studies have reported outcomes of per-oral endoscopic myotomy (POEM) in these patients. We conducted this study to systematically assess feasibility, safety, and efficacy of POEM on post-Heller patients.METHODS: Patients at least 3 months out from their POEM were selected from our prospective database: 318 consecutive POEMs performed from October 2009 to October 2016. The efficacy and safety of POEM were compared between the 46 patients with prior HM and the remaining 272 patients.RESULTS: Patients with prior Heller myotomy had longer disease history, more advanced disease, more type I and less type II achalasia, lower pre-POEM Eckardt score and lower pre-POEM LES pressure (all p<0.01). Procedure parameters and follow-up results (clinical success rate, Eckardt score, LES pressure, GERD score, esophagitis and pH testing) showed no significant difference between the 2 groups. For the 46 HM-POEM patients, no clinical significant perioperative adverse event occurred. Their overall clinical success (Eckardt score≤3 and no other treatment needed) rate was 95.7% at a median follow-up of 28 months.CONCLUSIONS: POEM as a rescue treatment for achalasia patients who failed Heller myotomy is feasible, safe, and highly effective. It should be the treatment of choice in managing these challenging cases at centers with a high level of experience with POEM.

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