Long-Term Outcomes of Peroral Endoscopic Myotomy in Achalasia Patients with a Minimum Follow-Up of 7 Years

Peroral endoscopic myotomy (POEM) has emerged as a transformative treatment for achalasia since its introduction in 2010. While its short- and medium-term efficacy and safety are well-established, questions regarding its long-term durability and outcomes beyond seven years remain unresolved. This study provides a comprehensive evaluation of POEM’s long-term effectiveness, symptom recurrence, complications, and postoperative dietary recommendations, based on a retrospective analysis of 32 achalasia patients with a median follow-up of 88 months.

Study Design and Patient Characteristics

The study retrospectively analyzed 39 patients who underwent POEM between December 2010 and June 2012 at a single institution. Of these, 32 patients (16 males, 16 females) completed a minimum follow-up of seven years by June 2019, with a median follow-up duration of 88 months (range: 84–103 months). The mean age of participants was 38.6 years (range: 19–58 years), and the median symptom duration before POEM was 24 months (range: 6–240 months). Four patients had undergone prior treatments for achalasia.

Preoperative preparations included a 48-hour fasting period and gastroscopy to confirm an empty esophagus. Intraoperatively, patients received general anesthesia and underwent standard POEM steps: mucosal incision (entry), submucosal tunneling, myotomy of the circular muscle layer, and wound closure. The median operative time was 65 minutes (range: 46–305 minutes), with a median myotomy length of 7.5 cm (range: 6–9 cm) and submucosal tunnel length of 12 cm (range: 9–14 cm).

Postoperative Management and Follow-Up Protocol

Postoperative care included a three-day fast followed by a progressive dietary regimen: liquids for one day, soft foods, and a regular diet resuming at one month. Patients received double-dose proton pump inhibitors (PPIs) and antibiotics for at least four weeks. Follow-up assessments occurred at 3, 6, and 12 months post-POEM, including gastroscopy, high-resolution manometry (HRM), and X-ray barium meal studies. The final evaluation in June 2019 focused on symptom severity via the Eckardt score, weight changes, and dietary habits.

Long-Term Clinical Outcomes

Treatment Efficacy

At seven years, 88% (28/32) of patients achieved treatment success, defined as an Eckardt score ≤3. The median Eckardt score decreased significantly from 7.0 (range: 6–10) preoperatively to 2.0 (range: 0–4) postoperatively (P < 0.05). Among treatment successes:

64% (18/28) maintained stable Eckardt scores over time.
29% (8/28) experienced score increases during follow-up, with symptom recurrence occurring at a median of 36 months (range: 6–72 months).
6% (2/28) showed score reductions.

Four patients (12%) were classified as treatment failures, with two exhibiting stable elevated scores and two experiencing worsening symptoms.

High-Resolution Manometry Findings

HRM data from 15 patients demonstrated a significant reduction in lower esophageal sphincter pressure (LESP) from a mean of 39.5 mmHg (range: 17.7–66.7 mmHg) preoperatively to 22.5 mmHg (range: 7.1–44.8 mmHg) postoperatively (P < 0.05).

Weight Changes

POEM improved nutritional outcomes, with 66% (21/32) gaining a median of 10 kg (range: 5–25 kg). Thirty-one percent (10/32) maintained stable weight, while one patient lost 8 kg.

Complications and Adverse Events

Intraoperative and Immediate Postoperative Complications

Gas-related complications occurred in 22% (7/32) of patients:

Pneumothorax requiring thoracic drainage (n = 3).
Subcutaneous emphysema or mediastinal emphysema resolving spontaneously within 2–3 days (n = 4).

Long-Term Reflux Events

Thirty-eight percent (12/32) reported clinical reflux symptoms, managed successfully with extended PPI therapy (median: 2.5 months).

Postoperative Dietary Recommendations

Based on patient feedback, four dietary strategies were correlated with better symptom control:

Alternate Eating and Drinking: Consuming fluids between bites of dry foods to facilitate bolus passage (endorsed by 15 patients).
Post-Meal Activity: Walking 10–30 minutes after dinner to reduce reflux risk (13 patients).
Timed Evening Fasting: Allowing ≥4 hours between dinner and bedtime (10 patients).
Avoidance of Irritants: Eliminating chili peppers, seafood, and alcohol (10 patients).

Discussion

This study confirms POEM’s long-term efficacy, with an 88% success rate at seven years, comparable to the 87% five-year success rate reported by Zhou et al. and similar to outcomes of laparoscopic Heller myotomy. The sustained reduction in LESP underscores POEM’s mechanistic validity in alleviating esophageal obstruction.

Symptom Recurrence and Refinement

Ten patients (31%) experienced Eckardt score increases during follow-up, emphasizing the need for ongoing monitoring. Late symptom recurrence (median: 36 months) may reflect incomplete myotomy, fibrosis, or disease progression, warranting further investigation.

Reflux Management

The 38% clinical reflux rate aligns with literature values (5–72.2%), influenced by heterogeneous definitions and technical variations. Prolonged PPI use and dietary modifications were effective in symptom control, though pH monitoring and endoscopic surveillance data would strengthen reflux assessment.

Limitations

The retrospective design and absence of a control group limit causal inferences. HRM follow-up was incomplete (47% compliance), potentially biasing physiological assessments.

Conclusions

POEM demonstrates durable efficacy in achalasia management, with stable symptom control in most patients beyond seven years. Postoperative dietary modifications, including timed eating, activity, and irritant avoidance, complement anatomical improvements to enhance quality of life. While reflux remains a concern, proactive management with PPIs and lifestyle adjustments mitigates its impact. Future prospective studies should validate dietary guidelines and explore predictors of late recurrence.

doi.org/10.1097/CM9.0000000000000735

Was this helpful?

0 / 0