Outcomes of peroral endoscopic myotomy in challenging achalasia patients: a long-term follow-up study

Peroral endoscopic myotomy (POEM) has been shown to be effective for achalasia patients. Our study aimed to analyze the clinical outcomes of POEM for challenging patients. We retrospectively enrolled 278 challenging achalasia patients who underwent POEM from January 2011 to July 2019. The outcomes of POEM such as procedure time, adverse events, and risk factors of adverse events were analyzed. Of the 278 patients (134 males and 144 females) with a mean age of 47.0 years, 103, 223, 93, and 98 patients had prior treatment and were Ling classification IIc/III, submucosal fibrosis (SMF) classification 2/3, and esophageal mucosa in achalasia (EMIA) classification c/d/e/f, respectively. The mean procedure time was 45.9 min (range, 15–158 min). The mean length of the tunnel and myotomy were 10.1 cm (range, 7–17 cm) and 6.6 cm (range, 5–13 cm), respectively. The major adverse event rate was 14.1%, while the minor adverse event rate was 4.7%. SMF classification 2/3 was an independent risk factor for incomplete tunneling, adverse events, and procedure time ≥ 90 min. The mean follow-up time was 37.2 months (range 1–99 months). The mean Eckardt score and esophageal sphincter pressure were both significantly declined postoperatively. The clinical success rate was 95.6%. POEM is safe and effective for challenging achalasia patients. SMF classification grade 2/3 was shown to be an independent risk factor for incomplete tunneling, adverse events, and procedure time ≥ 90 min. For these patients, POEM should be performed by experienced endoscopists, some cases are better served with traditional surgery, such as minimally invasive Heller with Dor fundoplication