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Updated: Jun 24, 2026
Use of the Scissor-Type Knife During the Peroral Endoscopy Myotomy Procedure for the Treatment of Achalasia
Published on: March 3, 2023
Peroral endoscopic myotomy as salvation technique post-Heller: International experience
Amy Tyberg1, Reem Z Sharaiha1, Pietro Familiari2
1Division of Gastroenterology and Hepatology, Weill Cornell Medical College, New York, USA.
Insights
Peroral endoscopic myotomy (POEM) offers a safe and effective treatment for achalasia patients with persistent symptoms after Heller myotomy (HM). This minimally invasive approach demonstrates high technical and clinical success rates, making it a viable option for symptom recurrence.
Area of Science:
- Gastroenterology
- Minimally Invasive Surgery
- Endoscopy
Background:
- Heller myotomy (HM) is a traditional treatment for achalasia.
- A significant number of patients experience persistent symptoms after HM.
- Limited data exist on managing recurrent achalasia symptoms post-HM.
Purpose of the Study:
- To evaluate the efficacy and safety of peroral endoscopic myotomy (POEM) in patients with persistent achalasia symptoms after prior HM.
- To assess long-term clinical outcomes and adverse events associated with post-HM POEM.
Main Methods:
- A prospective registry of 51 patients who underwent POEM after HM across 13 international centers (2012-2017).
- Technical success defined as successful myotomy completion.
- Clinical success defined as an Eckardt score ≤3 at 12-month follow-up.
- Adverse events (AE) were meticulously recorded.
Main Results:
- 100% technical success rate for POEM.
- 94% clinical success rate at 12 months, with a significant mean Eckardt score reduction.
- 7% of patients experienced adverse events, including mucosal defects and mediastinitis, managed conservatively or endoscopically.
Conclusions:
- POEM is a safe and effective salvage therapy for patients with persistent achalasia symptoms post-HM.
- POEM may become the preferred treatment option due to the challenges of repeat HM.
- Further long-term follow-up studies are warranted to confirm sustained efficacy.
Background:
Treatment for achalasia has traditionally been Heller myotomy (HM). Despite its excellent efficacy rate, a number of patients remain symptomatic post-procedure. Limited data exist as to the best management for recurrence of symptoms post-HM. We present an international, multicenter experience evaluating the efficacy and safety of post-HM peroral endoscopic myotomy (POEM).
Methods:
Patients who underwent POEM post-HM from 13 centers from January 2012 to January 2017 were included as part of a prospective registry. Technical success was defined as successful completion of the myotomy. Clinical success was defined as an Eckardt score of ≤3 on 12-month follow up. Adverse events (AE) including anesthesia-related, operative, and postoperative complications were recorded.
Results:
Fifty-one patients were included in the study (mean age 54.2, 47% male). Technical success was achieved in 100% of patients. Clinical success on long-term follow up was achieved in 48 patients (94%), with a mean change in Eckardt score of 6.25. Seven patients (13%) had AE: six experienced periprocedural mucosal defect treated endoscopically and two patients developed mediastinitis treated conservatively.
Conclusion:
For patients with persistent symptoms after HM, POEM is a safe salvation technique with good short-term efficacy. As a result of the challenge associated with repeat HM, POEM might become the preferred technique in this patient population. Further studies with longer follow up are needed.
