Post written by Li-Yun Ma, MD, from the Endoscopy Center and Endoscopy Research Institute, Shanghai Collaborative Innovation Center of Endoscopy, Zhongshan Hospital, Fudan University, Shanghai, China.

Repeat peroral endoscopic myotomy (Re-POEM) has appeared to be a promising salvage option for patients with persistent/recurrent symptoms after initial peroral endoscopic myotomy (POEM), but it may be more technical challenging. Herein, we aimed to evaluate the technical difficulty and safety between patients who underwent Re-POEM and those naïve POEM and investigate the risk factors for difficult Re-POEM.

Although POEM has proven to be highly effective as a first-line treatment for achalasia, a small proportion of patients remain symptomatic or experience relapse after POEM. Studies showed that Re-POEM appeared to be a safe and effective salvage option for patients with persistent/recurrent achalasia after prior POEM. However, Re-POEM may be more challenging because a prior POEM procedure may increase procedure difficulty or adverse events (AEs) and even aborted POEM. Few studies have systematically evaluated the technical difficulty of Re-POEM.

At the largest endoscopy center for POEM, we reviewed our experience in performing Re-POEM and evaluated the technical difficulty and safety between patients who underwent Re-POEM and those naïve POEM. With similar baseline characteristics between 2 groups after propensity score matching, the procedure time was comparable between Re-POEM and naïve POEM groups. Multivariate analysis determined mucosal edema and submucosal fibrosis to be independent risk factors for difficult Re-POEM. The Re-POEM group showed shorter esophageal myotomy and longer gastric myotomy lengths, probably because the operator intentionally performed a shorter myotomy because of the submucosal fibrosis and mucosal edema.

Several studies have demonstrated that the length of esophageal myotomy may not impact clinical success, and a short esophageal myotomy is noninferior to long myotomy with regard to clinical success, AEs, and GERD, which reduces the difficulty of establishing a submucosal tunnel, and saves some procedural time. Furthermore, a longer gastric myotomy can more effectively disrupt the lower esophageal sphincter, thereby improving clinical outcomes. Therefore, a short esophageal myotomy and a longer gastric myotomy may be an easier, safer, and potentially more effective approach in patients undergoing Re-POEM.

This study showed that procedure duration, incidence of AEs, and rate of technical difficulty were comparable between Re-POEM and naïve POEM groups. Mucosal edema and submucosal fibrosis were independent risk factors for difficult Re-POEM. However, this is a retrospective study in a tertiary referral center with experienced endoscopists, and our results may not be generalizable to other endoscopy centers. Re-POEM should be restricted to facilities where appropriate expertise is available to perform complicated procedures and manage potential AEs. Modified POEM, such as POEM with a short esophageal tunnel and myotomy and full-thickness myotomy, can be performed to shorten the operative time and thus may reduce incidence of AEs.

Repeat peroral endoscopic myotomy procedure. A, Radiographic image showing dilatation of the esophageal lumen and difficulty in passing barium through the cardia. B, Endoscopic image showing extensive food retention and mucosal redness. C, Mucosal scars of a previous peroral endoscopic myotomy. D, Submucosal tunneling. E, Full-thickness myotomy. F, Closure of the mucosal entry site.

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