Symptom duration is associated with esophageal remodeling in achalasia treated by peroral endoscopic myotomy

Symptom duration may reflect cumulative disease burden in achalasia, but its relation to objective recovery after peroral endoscopic myotomy (POEM) remains unclear. In this single-center prospective observational cohort, 68 eligible patients treated with POEM were stratified by preoperative symptom duration (< 3 years, 3-10 years, and > 10 years). Clinical success was defined as an Eckardt score ≤ 3 at 3 and 6 months. Secondary outcomes included perioperative safety, persistent symptoms, high-resolution manometry, barium esophagram morphology, and subtype distribution. All patients underwent technically successful POEM without severe adverse events, and all achieved clinical success at both follow-up time points; therefore, the study could describe short-term clinical response but could not identify predictors of clinical failure. Longer symptom duration was associated preoperatively with more prior treatment, lower integrated relaxation pressure and lower esophageal sphincter pressure, more advanced esophageal remodeling, fewer type II cases, and more unclassified cases. Among 58 patients with objective 3-month reassessment, manometric and morphologic parameters improved significantly after POEM, although morphologic recovery was less complete in patients with the longest symptom duration. These findings suggest that symptom duration is better interpreted as a marker of cumulative disease remodeling than as an isolated determinant of short-term symptomatic success after POEM.