Efficacy and safety of peroral endoscopic myotomy in the management of recurrent achalasia after failed Heller myotomy: a systematic review and meta-analysis

BACKGROUND: Heller myotomy (HM) is an established treatment for achalasia but can fail in up to 10-20% of patients. Peroral endoscopic myotomy (POEM) may be an appropriate treatment for patients with failed HM. METHODS: We searched several databases to identify non-comparative studies evaluating the efficacy and/or safety of POEM after failed HM and comparative studies comparing the efficacy and/or safety of POEM in patients with and without prior HM. Outcomes assessed included clinical success, technical success, adverse events, post-treatment gastroesophageal reflux disease (GERD), and presence of esophagitis on endoscopy. We calculated weighted pooled rates with 95% confidence intervals (CI) for all outcomes in patients undergoing POEM with prior HM. We calculated pooled odds ratios with 95%CI to compare the outcomes between patients with and without previous HM who underwent POEM. RESULTS: We included 11 observational studies with 1205 patients. Weighted pooled rates (95%CI) for overall clinical success and technical success in patients with failed HM were 87% (81-91%) and 97% (94-99%), respectively. Weighted pooled rates (95%CI) for major adverse events, new-onset GERD and presence of esophagitis on endoscopy were 5% (2-10%), 33% (26-41%), and 38% (22-58%), respectively. There were no differences in clinical success, adverse events, post-treatment GERD and esophagitis between patients with and without previous HM. CONCLUSIONS: POEM is safe and effective in patients with failed HM and should be considered in patients with recurrent achalasia after HM. Outcomes of POEM are comparable in patients with and without prior HM.