Ichkhanian Y, Assis D, Familiari P, Ujiki M, Su B, Khan SR, Pioche M, Draganov PV, Cho JY, Eleftheriadis N, Barret M, Haji A, Velanovich V, Tantau M, Marks JM, Bapaye A, Sedarat A, Albeniz E, Bechara R, Kumta NA, Costamagna G, Perbtani YB, Patel M, Sippey M, Korrapati SK, Jain R, Estremera F, El Zein MH, Brewer Gutierrez OI, and Khashab MA
Background: Although peroral endoscopic myotomy (POEM) is highly effective for the management of achalasia, clinical failures may occur. The optimal management of patients who fail POEM is not well known. This study aimed to compare the outcomes of different management strategies in patients who had failed POEM., Methods: This was an international multicenter retrospective study at 16 tertiary centers between January 2012 and November 2019. All patients who underwent POEM and experienced persistent or recurrent symptoms (Eckardt score > 3) were included. The primary outcome was to compare the rates of clinical success (Eckardt score ≤ 3) between different management strategies. RESULTS : 99 patients (50 men [50.5 %]; mean age 51.4 [standard deviation (SD) 16.2]) experienced clinical failure during the study period, with a mean (SD) Eckardt score of 5.4 (0.3). A total of 29 patients (32.2 %) were managed conservatively and 70 (71 %) underwent retreatment (repeat POEM 33 [33 %], pneumatic dilation 30 [30 %], and laparoscopic Heller myotomy (LHM) 7 [7.1 %]). During a median follow-up of 10 (interquartile range 3 - 20) months, clinical success was highest in patients who underwent repeat POEM (25 /33 [76 %]; mean [SD] Eckardt score 2.1 [2.1]), followed by pneumatic dilation (18/30 [60 %]; Eckardt score 2.8 [2.3]), and LHM (2/7 [29 %]; Eckardt score 4 [1.8]; P = 0.12). A total of 11 patients in the conservative group (37.9 %; mean Eckardt score 4 [1.8]) achieved clinical success. CONCLUSION : This study comprehensively assessed an international cohort of patients who underwent management of failed POEM. Repeat POEM and pneumatic dilation achieved acceptable clinical success, with excellent safety profiles., Competing Interests: Dr. Costamagna is a consultant for Cook Medical, Boston Scientific, and Olympus, and has an Olympus research grant. Dr. Ujiki has received grants and personal fees from Boston Scientific and Gore, and personal fees from Olympus and Medtronic, outside of the the submitted work. Dr. Draganov is a consultant for Olympus, BSC, Cook, Lumendi, and Microtech. Dr. Velanovich receives payment for speakers’ bureau service from A-Cell, Inc. Dr. Marks is a consultant for Boston Scientific and Olympus. Dr. Sedarat is a consultant for Boston Scientific. Dr. Kumta is a consultant for Boston Scientific, Olympus, and Apollo Endosurgery. Dr. Khashab is a consultant for Boston Scientific, Medtronic, and Olympus., (Thieme. All rights reserved.)