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When the gold standard fails: Propensity-matched comparison of peroral endoscopic myotomy after Heller myotomy versus index peroral endoscopic myotomy

  • 0Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio.
The Journal of Thoracic and Cardiovascular Surgery +

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October 17, 2025

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October 17, 2025

View abstract on PubMed

Summary

This summary is machine-generated.

Salvage peroral endoscopic myotomy (POEM) for achalasia after Heller myotomy (HM) offers durable symptom relief but is less effective than initial POEM. Patients undergoing POEM after HM require closer monitoring due to potentially less favorable long-term outcomes.

Area Of Science

  • Gastroenterology
  • Minimally Invasive Surgery
  • Endoscopy

Background

  • Heller myotomy (HM) is the standard achalasia treatment, but symptoms can recur.
  • Peroral endoscopic myotomy (POEM) is an alternative, including as salvage therapy after HM.
  • Long-term comparative data for salvage POEM versus initial POEM are limited.

Purpose Of The Study

  • To compare the long-term outcomes of POEM performed after HM (salvage) versus POEM as an initial procedure (index).
  • To evaluate differences in symptom control, esophageal emptying, esophagitis, and reintervention rates between the two groups.

Main Methods

  • Retrospective analysis of 381 achalasia patients undergoing POEM (April 2014-January 2023).
  • 84 patients had prior HM (POEM-after-HM group), 297 had no prior myotomy (index-POEM group).
  • Propensity-score matching created 62 pairs; median follow-up was 3 years.

Main Results

  • Operative metrics and complications were similar. Symptom palliation at 5 years was 67% for POEM-after-HM vs. 80% for index-POEM (P=.028).
  • Esophageal emptying and esophagitis rates were comparable. Reinterventions by 5 years: 10 after salvage POEM vs. 4 after index POEM (P=.24).

Conclusions

  • Salvage POEM provides durable achalasia symptom palliation but is less effective than index POEM.
  • Prior HM may limit salvage POEM efficacy due to fibrosis or surgical alterations.
  • Recommend closer follow-up for patients receiving salvage POEM after HM.

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