The efficacy of peroral endoscopic myotomy vs. pneumatic dilation as treatment for patients with achalasia suffering from persistent or recurrent symptoms after laparoscopic Heller myotomy. A RANDOMIZED CLINICAL TRIAL

Background & aims: For achalasia patients with persistent or recurrent symptoms after laparoscopic Heller myotomy (LHM), pneumatic dilation (PD) is the most frequently used treatment. Per-oral endoscopic myotomy (POEM) is increasingly being investigated as rescue therapy. This study aimed to determine the efficacy of POEM versus PD for patients with persistent or recurrent symptoms after LHM. Methods: This randomized multicenter controlled trial included patients after LHM with an Eckardt score >3 and significant stasis (≥2 cm) on timed barium esophagogram, randomized to POEM or PD. The primary outcome was treatment success, defined as an Eckardt score of ≤3, without unscheduled retreatment. Secondary outcomes included the presence of reflux esophagitis, HRM, and timed barium esophagogram findings. Follow-up duration was 1 year after initial treatment. Results: Ninety patients were included. POEM had a higher success rate (28 of 45 patients [62.2%]) than PD (12 of 45 patients [26.7%] (absolute difference, 35.6% [95%CI, 16.4%-54.7%]; [p=0.001); OR, 0.22 [95%CI, 0.09-0.54]; RR for success 2.33 [95%CI, 1.37-3.99]. Reflux esophagitis was not significantly different between POEM (12 of 35 [34.3%]) and PD (6 of 40 [15%]). Basal LES pressure and IRP-4 were significantly lower in the POEM group [p=0.034; p=0.002]. Barium column height after 2 and 5 minutes was significantly less in patients treated with POEM [p=0.005; p=0.015]. Conclusion: Among achalasia patients with persistent or recurrent symptoms after LHM, POEM resulted in a significantly higher success rate than PD, with a numerically higher incidence of grade A-B reflux esophagitis.