POEM Better Than Pneumatic Dilation in Treating Achalasia Symptoms After Surgical Myotomy

Research into peroral endoscopic myotomy (POEM) as a rescue therapy for patients with persistent or recurrent symptoms after laparoscopic Heller myotomy (LHM) is increasing. Although case series suggest that POEM has high efficacy rates ranging from 81% to 100% when used as a rescue therapy after LHM, no studies have compared POEM to other therapy methods, such as pneumatic dilation (PD). 

In this multicenter randomized controlled trial, patients who had undergone LHM and had an Eckardt score >3 and significant stasis (≥2 cm) on timed barium esophagogram were randomly assigned to either POEM or PD. The primary outcome was treatment success, defined as an Eckardt score of ≤3 without unscheduled retreatment; secondary outcomes included reflux esophagitis, high-resolution manometry, and timed barium esophagogram findings. 

Results showed that at 1 year of follow-up, of the 90 patients included, POEM had a higher success rate (62.2%) than PD (26.7%), with a significant difference (P=.001) and decreases in basal lower esophageal sphincter pressure and integrated residual pressure-4. Although reflux esophagitis was numerically higher in the POEM group, it was not significantly different between the two groups. However, barium column height was significantly lower after 2 and 5 minutes in patients treated with POEM.