Repeat peroral endoscopic myotomy: technical difficulty and risk factors

Area of Science:

• Gastroenterology
• Endoscopic Surgery
• Digestive Disease Management

Background:

• Persistent or recurrent achalasia symptoms after peroral endoscopic myotomy (POEM) necessitate salvage treatment.
• Repeat POEM (Re-POEM) is a potential option but may present increased technical challenges.

Purpose of the Study:

• To evaluate the safety and technical difficulty of Re-POEM.
• To compare Re-POEM outcomes with initial (naïve) POEM.

Main Methods:

• Retrospective analysis of 158 patients undergoing Re-POEM and 2978 patients undergoing naïve POEM (July 2012-October 2023).
• Propensity score matching (PSM) to create comparable groups.
• Comparison of procedure-related parameters, including procedure time, myotomy length, and adverse events (AEs).
• Multivariable analysis to identify risk factors for difficult Re-POEM (procedure time ≥90 minutes).

Main Results:

• After PSM, procedure times were comparable between Re-POEM and naïve POEM groups (61.4 ± 27.0 vs 59.3 ± 29.9 minutes).
• Re-POEM involved shorter esophageal myotomy but longer gastric myotomy lengths.
• Mucosal injury, gas-related AEs, major AEs, and technical difficulty were similar between groups.
• Mucosal edema and submucosal fibrosis were identified as independent risk factors for difficult Re-POEM.

Conclusions:

• Re-POEM is a safe and feasible salvage therapy for patients with failed initial POEM.
• Technical difficulty and adverse event rates are comparable to naïve POEM.
• Mucosal edema and submucosal fibrosis predict challenges in Re-POEM procedures.