Esophageal morphology does not predict post-operative outcomes after peroral endoscopic myotomy

Peroral Endoscopic Myotomy (POEM) is a minimally invasive and effective treatment for esophageal motility disorders like achalasia. While POEM achieves high success rates, the influence of esophageal morphology on post-operative outcomes remains unclear. Existing studies focus on symptom resolution and manometric changes, but limited data assess whether features such as esophageal diameter, and angulation impact treatment failure or the need for additional interventions.

We retrospectively analyzed achalasia patients who underwent POEM at a single institution (2012-2024). Patients were grouped by esophageal morphology from preoperative timed barium swallow: esophageal diameter (< 3 cm, 3-5 cm, > 5 cm), and angulation, and bird's beak appearance. POEM failure was defined as the need for repeat intervention, symptom recurrence, or post-operative Eckardt score > 3. Multivariable logistic regression assessed associations between morphology and outcomes.

Among 88 patients, esophageal diameter > 5 cm was more frequently associated with bird's beak appearance (71% vs. 65% vs. 31%, p < 0.05). Bird's beak appearance was linked to higher post-operative IRP (44.0 mmHg vs. 12.8 mmHg, p = 0.03) but not to symptom recurrence. Increased esophageal angle was significantly associated with post-operative endoscopic intervention (140.3° vs. 127.8°, p = 0.02), though diameter and bird's beak appearance were not predictive POEM outcomes.

Esophageal morphology does not significantly impact symptom recurrence or the need for repeat interventions post-POEM. However, an increased esophageal angle may predict the need for post-operative endoscopic intervention. These findings suggest that esophageal morphology should not be considered a contraindication to POEM.