Peroral endoscopic myotomy in treatment-naive achalasia patients versus prior treatment failure cases

Background and study aim Peroral endoscopic myotomy (POEM) has emerged as an effective treatment modality for achalasia. Prior treatment may affect the outcomes of subsequent management. In this study, we aimed to compare the safety and efficacy of POEM in treatment-naive patients vs. those with prior treatment failure (PTF). Patients and methods The data of consecutive patients with achalasia who underwent POEM at a single tertiary care center from January 2013 to November 2016 were analyzed retrospectively. A comparative analysis was performed between treatment-naive and PTF cases. Technical and clinical success, adverse events, and operative time for POEM were compared between the two groups. Results Overall, 502 patients with achalasia underwent POEM during the study period: 260 patients (51.8%) in the treatment-naive group and 242 patients (48.2%) in the PTF group. The mean operative time was significantly longer in the PTF group compared with the treatment-naive group (74.9 +/- 30.6 vs. 67.0 +/- 27.1 minutes; P = 0.002). On multi-variate analysis, type of achalasia, dilated esophagus (>6 cm), disease duration, prior treatment, occurrence of adverse events, and type of knife used were significant predictors of operative time. Technical success (98.1% vs. 97.1%; P=0.56) and clinical success (92.4% vs. 92.5%; P = 0.95) were comparable in the treatment-naive and PTF cases, respectively. Occurrence of gas-related events and mucosotomy were similar in both groups. Elevated DeMeester score was found in 17 / 53 patients (32.1%) in the PTF group and in 11 / 44 patients (25.0%) in the treatment-naive group (P=0.50). Conclusion POEM is safe and equally effective for treatment-naive patients and for those in whom prior treatment has failed. POEM should be considered the treatment of choice in patients in whom prior treatment has failed.