Aims Achalasia is a motility disorder of the esophagus characterized by aperistalsis in
the esophageal body coupled with impaired relaxation of the lower esophageal sphincter.
Peroral Endoscopic Myotomy (POEM) represents a novel therapeutic alternative. However,
data on its effectiveness and morbidity are limited, and its potential superiority
over pneumatic dilation remains under discussion. The objective of our study was to
evaluate the effectiveness and complications of POEM as a first-line treatment for
achalasia.
Methods This is a prospective monocentric cohort study initiated in May 2023. POEM was performed
following the four standard steps: mucosal incision, submucosal tunneling, myotomy,
and mucosal incision closure. Clinical success was assessed using three parameters:
Eckardt score≤3 one month post-POEM, reduction of the Integrated Relaxation Pressure
(IRP) and Resting Pressure (RP) by more than 50% on esophageal manometry at three
months, and weight gain exceeding 5 kg within three months.
Results 14 patients underwent POEM for achalasia in our endoscopy unit. The 13 treatment-naive
patients were included in this study. The median age in our series was 47 years[38;60].
7 patients had type 1 achalasia (54%), 5 had type 2 achalasia (39%), and one patient
had type 3 achalasia. The median IRP was 31.5 [21.8;34.8], while the mean resting
pressure was 35.6±10.9. Clinical symptoms included dysphagia, retrosternal pain, regurgitation,
and weight loss exceeding 10 kg, with an Eckardt score of 12 in 100% of our patients.
The median duration of symptom progression was 13 months [7;48]. Technical success
was achieved in 90.9% of cases, with one technical failure in a patient whose symptoms
had progressed for 14 years, presenting with a very dilated and tortuous esophagus
and extensive submucosal fibrosis that prevented any attempt at tunneling. Complications
occurred during the procedure in 25% of cases, including 3 cases of simple pneumoperitoneum
immediately managed by needle decompression and one case of bilateral capnothorax
treated with dual thoracic drainage, which evolved very well. Clinical success was
90.9%. All our patients had an Eckardt score≤3 post-POEM. The median pre-POEM IRP
was 31.5 [21.8;34.8] vs 9.2 [6.4;12] post-POEM, with a statistically significant difference
between the two (p=0.016). Only the patient with type 3 achalasia showed less than
a 50% reduction in IRP post-POEM. Nevertheless, the Eckardt score remained at 3. There
was also a statistically significant difference in the average weight of our patients
pre-POEM (67.3±12.6kg) and post-POEM (76.4±13.5kg) (p=0.004). Our patients gained
an average of 9±4.1 kg over the three months following POEM.
Conclusions In our experience, POEM was associated with a notable improvement in symptoms, with
a success rate of 90.9% and a low complication rate. It appears to be a safe and minimally
invasive procedure when there is awareness of complications and their optimal management
