Abstract
Background:
Per-oral endoscopic myotomy (POEM) has emerged as a minimally invasive treatment for achalasia, with growing global adoption. However, regional data from Saudi Arabia are scarce. This study aimed to evaluate the efficacy, safety, and long-term outcomes of POEM in a tertiary referral center in Riyadh.
Methods:
We conducted a retrospective cohort study of all consecutive patients with achalasia who underwent POEM at King Faisal Specialist Hospital and Research Centre between April 2017 and October 2023. Diagnosis was confirmed by high-resolution manometry and classified using the Chicago Classification v3.0 or v4.0. Clinical success was defined as an Eckardt score ≤3 at follow-up. Secondary outcomes included adverse events, gastroesophageal reflux disease (GERD), and need for further intervention.
Results:
A total of 105 patients (mean age 41.2 ± 13.9 years; 50.5% male) underwent POEM. The majority had type II achalasia (77.1%), followed by type III (12.4%) and type I (10.5%). Prior interventions were recorded in 25.7% of patients. Clinical success was achieved in 77.1%, with a significant reduction in mean Eckardt score (6.8 ± 2.3 to 1.8 ± 1.7; P < 0.001). The median follow-up was 1118 days. Patient satisfaction (≥80% symptom relief) was 69.5%. Complications occurred in 26.7%, predominantly gas-related events, with no procedure-related mortality. Major adverse events were rare (perforation 1.9%, reoperation 1.9%). Post-POEM GERD was confirmed in 24.4% of those tested with the Ph study, and 58.8% required proton pump inhibitor therapy at follow-up. Comparative analysis across time periods showed no significant difference in complication rates, although hospital stay was longer in the later cohort. Multivariable analysis did not identify independent predictors of clinical success.
Conclusion:
POEM is a safe and effective treatment for achalasia in Saudi Arabia, achieving substantial symptom relief with acceptable complication rates, consistent with international experience. The notable incidence of post-procedure GERD underscores the need for long-term reflux monitoring and management.
Keywords: Achalasia, Eckardt score, gastroesophageal reflux disease (GERD), minimally invasive treatment, per-oral endoscopic myotomy (POEM), Saudi Arabia
INTRODUCTION
Achalasia is a rare esophageal motility disorder characterized by impaired relaxation of the lower esophageal sphincter (LES) and absent peristalsis in the esophageal body, leading to symptoms such as dysphagia, regurgitation, and weight loss.[1,2,3] The primary goal of treatment is to relieve symptoms by reducing LES pressure, thereby improving esophageal emptying. Current treatment modalities include pharmacological therapy, endoscopic balloon dilation (EBD), laparoscopic Heller myotomy (LHM), and per-oral endoscopic myotomy (POEM). Each approach has its advantages and limitations, making the choice of treatment dependent on patient-specific factors and disease characteristics.[1,2,3,4,5]
Pharmacological therapy, such as calcium channel blockers and nitrates, offers a noninvasive option but is often limited by transient efficacy and systemic side effects, making it unsuitable for long-term management.[6,7] EBD is a minimally invasive procedure that mechanically disrupts the LES, providing symptom relief in approximately 70–90% of patients. However, it carries a risk of esophageal perforation (2–5%) and often requires repeated procedures due to symptom recurrence.[8,9] LHM combined with fundoplication has been the gold standard surgical treatment, offering durable symptom relief in over 90% of cases. Nevertheless, it is invasive, requires general anesthesia, and is associated with risks such as postoperative gastroesophageal reflux disease (GERD) and surgical complications.[10,11,12,13]
In recent years, POEM has emerged as a promising minimally invasive alternative. POEM involves creating a submucosal tunnel endoscopically and performing a myotomy of the LES and proximal gastric muscle fibers. Compared to LHM, POEM offers comparable efficacy with shorter procedure times, reduced postoperative pain, and faster recovery.[13,14,15,16] Additionally, POEM is particularly advantageous in patients with type III (spastic) achalasia or those who have failed prior treatments as it allows for a longer and more tailored myotomy.[17,18,19] However, POEM is not without limitations. The procedure is technically demanding and requires specialized training. It also carries risks such as mucosal perforation, pneumothorax, and post-procedure GERD, which may necessitate long-term proton pump inhibitor therapy.[20,21] Furthermore, POEM may not be suitable for patients with severe comorbidities, prior esophageal surgeries, or significant esophageal fibrosis as these factors can increase procedural complexity and risk.[11]
Despite its growing adoption, data on POEM outcomes in specific populations, such as those in Saudi Arabia, remain limited. This study aims to evaluate the efficacy, safety, and long-term outcomes of POEM in a single-center cohort from Saudi Arabia, addressing gaps in regional data. The objectives of this study are to: (1) assess the clinical success rate of POEM in relieving achalasia symptoms, (2) identify factors associated with treatment failure or complications, (3) evaluate the incidence of post-POEM GERD, and (4) determine the suitability of POEM for different achalasia subtypes in this population. By providing region-specific insights, this study aims to contribute to the global understanding of POEM and guide clinical decision-making for achalasia management.
PATIENTS AND METHODS
Study design and setting
This single-center, retrospective cohort study was conducted at King Faisal Specialist Hospital and Research Centre (KFSHRC) in Riyadh, Saudi Arabia, a tertiary referral center with a high-volume endoscopy unit specializing in advanced therapeutic procedures. The study included all consecutive patients diagnosed with achalasia who underwent POEM procedures between April 23, 2017 and October 23, 2023. The study protocol was reviewed and approved by the Institutional Review Board (IRB) of KFSHRC with RAC number 2211085.
Inclusion and exclusion criteria
The diagnosis of achalasia was confirmed in all patients by high-resolution manometry (HRM) and classified according to the Chicago Classification version 3.0 and 4.0.[22,23] Patients with a prior history of achalasia treatments, including pneumatic dilation or LHM, were eligible for inclusion.
Exclusion criteria were as follows: (1) inability or refusal to provide informed consent, (2) severe cardiopulmonary comorbidities or instability precluding safe endoscopic intervention under general anesthesia, (3) significant esophageal fibrosis or anatomic distortion from prior surgery (other than LHM) that would technically complicate the POEM procedure, (4) pregnancy, (5) evidence of malignant or active inflammatory esophageal conditions, and (6) previous unsuccessful POEM procedure. Patients who underwent POEM for indications other than achalasia were also excluded.
The POEM procedure
All POEM procedures were performed by expert endoscopists with formal training and extensive experience in advanced therapeutic endoscopy. The technique adhered to standardized principles described by Inoue et al.[24] Briefly, under general anesthesia with endotracheal intubation and carbon dioxide insufflation, a submucosal injection of normal saline mixed with indigo carmine was administered in the mid-esophagus to create a mucosal bleb. A 2-cm longitudinal mucosal incision was made to access the submucosal space. A submucosal tunnel was then created, extending approximately 3–4 cm distal to the gastroesophageal junction (GEJ) into the gastric cardia. A selective myotomy of the circular muscle bundle was performed, starting 3 cm distal to the mucosal incision and extending 2–3 cm onto the gastric cardia. The myotomy was performed in either full-thickness manner for type III achalasia or selective circular manner for types I and II, at the endoscopist’s discretion. The mucosal entry site was subsequently closed with through-the-scope or over-the-scope hemostatic clips. Intraoperative endoscopic assessment was performed to confirm adequate myotomy length and GEJ patency.
Data collection and outcome measures
Demographic, clinical, manometric, and procedural data were prospectively collected and maintained in a dedicated electronic database. For any missing information, a comprehensive retrospective review was conducted using patient medical records, endoscopic reports, manometry studies, pH studies, and operative notes. All data were finalized and verified by December 31, 2023, with a subsequent comprehensive update completed on August 31, 2025, to ensure completeness.
Collected variables included patient age, sex, body mass index (BMI), American Society of Anesthesiologists (ASA) class, achalasia subtype, previous treatments, procedural details (duration, myotomy length, tunnel length), and intraoperative adverse events. Two patients under 18 years of age were included in the analysis.
The primary outcome was clinical success, defined as a post-POEM Eckardt score of ≤3 at the first follow-up assessment (typically 2–3 months postprocedure). For patients who did not attend the scheduled 3-month clinic visit, the Eckardt score was collected during their first clinical encounter with a physician following the POEM procedure. Secondary outcomes included procedural adverse events (classified according to the ASGE lexicon), incidence of postprocedure GERD, and the need for proton pump inhibitor (PPI) therapy. GERD was objectively assessed via 24-hour impedance-pH monitoring or upper endoscopy (with findings of erosive esophagitis or Barrett’s esophagus) in symptomatic patients. Patient-reported subjective improvement was also recorded and categorized as satisfactory if patients reported ≥80% global symptom relief.
Statistical analysis
Descriptive statistics were used to summarize the cohort characteristics. Continuous variables were expressed as mean ± standard deviation (SD) for normally distributed data or as median with interquartile range (IQR) for non-normally distributed data. Categorical variables were reported as frequencies and percentages (n, %). The primary outcome, clinical success, was analyzed on an intention-to-treat basis. Univariate analyses (Student’s t-test, Mann–Whitney U test, Chi-square, or Fisher’s exact test, as appropriate) were performed to identify factors associated with clinical success and complications. Variables with a P value < 0.1 in univariate analysis were included in a multivariable logistic regression model to identify independent predictors. A two-sided P value of < 0.05 was considered statistically significant. All statistical analyses were performed using Jamovi (version 2.3.28), open-source statistical software (The Jamovi project, 2025, https://www.jamovi.org).
RESULTS
Patient demographics and baseline characteristics
A total of 105 patients underwent POEM for achalasia during the study period. The mean age was 41.2 ± 13.9 years, 50.5% were male, and the mean BMI was 25.5 ± 6.6 kg/m2. The majority of patients were classified as ASA II (55.2%). Based on the Chicago classification, type II achalasia (77.1%) was the most common subtype, followed by type III (12.4%) and type I (10.5%). Patients had a mean preoperative Eckardt score of 6.8 ± 2.3 and a mean symptom duration of 4.7 ± 4.9 years. A quarter of the cohort (25.7%) had undergone at least one previous intervention, predominantly pneumatic dilation (15.2%) or botulinum toxin injection (11.4%). The baseline characteristics of the cohort are summarized in Table 1.
Table 1.
Baseline characteristics and outcomes of 105 patients undergoing peroral endoscopic myotomy (POEM) for achalasia cardia
| Characteristics | Overall (N=105) |
|---|---|
| Demographics | |
| Gender, n (%) | |
| Male | 53 (50.5%) |
| Female | 52 (49.5%) |
| Age, years, mean (SD) [range] | 41.2 (13.9) [12.0-73.0] |
| BMI, kg/m2, mean (SD) [range] | 25.5 (6.6) [14.2-41.6] |
| ASA classification, n (%) | |
| I | 33 (31.4%) |
| II | 58 (55.2%) |
| III | 14 (13.3%) |
| Disease characteristics | |
| Type of achalasia, n (%) | |
| Type I | 11 (10.5%) |
| Type II | 81 (77.1%) |
| Type III | 13 (12.4%) |
| Duration of symptoms, years, mean (SD) [range] | 4.7 (4.9) [0.8-20.0] |
| Preoperative Eckardt score, mean (SD) [range] | 6.8 (2.3) [3.0-11.0] |
| Preoperative workup | |
| Barium swallow findings, n (%) | |
| Achalasia | 103 (98.1%) |
| Corkscrew esophagus | 1 (1.0%) |
| Unremarkable | 1 (1.0%) |
| High-resolution manometry | |
| Mean IRP, mm Hg, mean (SD) [range]1 | 35.5 (16.1) [6.0-90.0] |
| Resting LES pressure, mm Hg, mean (SD) [range]2 | 45.8 (20.6) [12.9-127.0] |
| Previous Interventions | |
| Any previous intervention, n (%) | 27 (25.7%) |
| Type of previous intervention, n (%) | |
| Botulinum toxin injection | 12 (11.4%) |
| Pneumatic dilation3 | 16 (15.2%) |
| Both (Botulinum toxin and dilation)4 | 1 (1.0%) |
| Number of pneumatic dilations, n (%)5 | |
| 0 | 89 (84.8%) |
| 1 | 3 (2.9%) |
| 2 | 8 (7.6%) |
| 3 | 4 (3.8%) |
| 4 | 1 (1.0%) |
| Previous laparoscopic Heller myotomy, n (%)6 | 0 (0.0%) |
| Procedure details | |
| Myotomy length, cm, mean (SD) [range]7 | 9.6 (1.4) [4.0-13.0] |
| Submucosal tunnel length, cm, mean (SD) [range]8 | 12.1 (1.1) [8.0-15.0] |
| Proximal mucosotomy distance, cm, mean (SD) [range]9 | 9.9 (0.8) [5.0-13.0] |
| Mucosotomy site, n (%)10 anterior | 104 (100.0%) |
| Outcomes | |
| Hospital stays, days, mean (SD) [range] | 3.8 (2.6) [1.0-20.0] |
| Postoperative Eckardt score, mean (SD) [range] | 1.8 (1.7) [0.0-6.0] |
| Clinical success (Eckardt score ≤3), n (%) | 81 (77.1%) |
| Patient satisfaction (≥80%), n (%) | 73 (69.5%) |
| Postoperative manometry | |
| Performed, n (%) | 61 (58.1%) |
| Mean IRP, mm Hg, mean (SD) [range]11 | 9.7 (7.1) [0.0-31.6] |
| Postoperative pH monitoring | |
| Performed, n (%) | |
| Findings, n (% of tested)12 | 41 (39.0%) |
| Acidic reflux | 10 (24.4%) |
| No significant reflux | 34 (75.6%) |
| Postoperative PPI use, n (%)13 | 47 (58.8%) |
| Complications, n (%) | 28 (26.7%) |
| Mortality, n (%) | 0 (0.0%) |
| Management of failure/recurrence (n=29)14 | |
| Conservative management | 15 (51.7%) |
| Pneumatic dilation (PD) | |
| Planned | 3 (10.3%) |
| Performed | 5 (17.2%) |
| Botulinum toxin injection | |
| Performed | 1 (3.4%) |
| Performed + PD | 2 (6.9%) |
| Heller’s myotomy | |
| Planned | 1 (3.4%) |
| Performed | 2 (6.9%) |
| Follow-up | |
| Follow-up, days, mean (SD) [range] | 1118.0 (841.3) [2.0-3001.0] |
1Data missing for 2 patients. 2Data missing for 1 patient. 3Denominator for percentage is the overall cohort (N=105). 4Denominator for percentage is the overall cohort (N=105). 5Number of dilations prior to POEM. Denominator for percentages is N=105. 6Data missing for 1 patient. Confirmed no previous LHM in 104/104 patients. 7Data missing for 7 patients. 8Data missing for 6 patients. 9Data missing for 13 patients. 10Data missing for 1 patient. 11Data on postoperative mean IRP missing for 41 patients. 12Denominator for pH findings is the number of patients tested (n=41). 61 patients were not tested. 13Data missing for 25 patients. Denominator for percentage is 80. 14Analysis includes 29 patients who had a failed outcome (n=24) or required re-intervention despite initial success. Percentages are calculated from this subgroup (n=29). The “Successful result” row (n=76) from the original data is represented by its inverse in this subgroup analysis
Procedural outcomes and efficacy
The procedure was highly effective, with a clinical success (Eckardt score ≤3) rate of 77.1% and a patient satisfaction rate (≥80% improvement) of 69.5%. The mean postoperative Eckardt score significantly decreased to 1.8 ± 1.7. The mean hospital stay was 3.8 ± 2.6 days. Complications occurred in 26.7% of patients with no mortality. Among the 41 patients who underwent postoperative pH monitoring, acidic reflux was detected in 24.4%. Subsequently, 58.8% of patients were on proton pump inhibitor therapy at follow-up. Management for failure or recurrence (n = 29) was primarily conservative (51.7%), with a subset requiring pneumatic dilation (17.2%) or surgical intervention (6.9%) [Table 1].
Postoperative complications and management
Procedural or postoperative complications occurred in 28 (26.7%) of the 105 patients. The types of complications and their management are detailed in Table 2. The most frequently observed adverse events were gas-related, with pneumoperitoneum occurring in 14 patients (13.3%), and both subcutaneous emphysema and pneumomediastinum observed in 12 patients each (11.4%). Procedure-related findings were less common, including radiographic leak (5.7%), bleeding (2.9%), and esophageal perforation (1.9%). Major clinical outcomes were rare, with return to the operating room required for 2 patients (1.9%) and a single case (1.0%) of aspiration pneumonia.
Table 2.
Incidence and management of complications following peroral endoscopic myotomy (POEM) in 105 patients
| Complication | n (%) |
|---|---|
| Procedure-related findings | |
| Postoperative leak (radiographic) | 6 (5.7) |
| Bleeding | 3 (2.9) |
| Mucosal ulceration | 1 (1.0) |
| Esophageal perforation | 2 (1.9) |
| Esophageal diverticulum | 1 (1.0) |
| Dehiscence of the tunnel opening | 2 (1.9) |
| Gas-related events | |
| Subcutaneous emphysema | 12 (11.4) |
| Pneumoperitoneum | 14 (13.3) |
| Pneumomediastinum | 12 (11.4) |
| Pneumothorax | 5 (4.8) |
| Major clinical outcomes | |
| Return to the operating room | 2 (1.9) |
| Aspiration pneumonia | 1 (1.0) |
| Management of complications (n=15 events*) | |
| Conservative management | 5 (33.3) |
| Endoscopic management | |
| Closure with clips | 3 (20.0) |
| Stent placement | 2 (13.3) |
| Coagulation forceps/hemostatic agent | 1 (6.7) |
| Interventional/surgical management | |
| Chest tube insertion | 1 (6.7) |
| Needle decompression (pneumoperitoneum) | 1 (6.7) |
| Surgery, washout, repair, and stent | 1 (6.7) |
*Some cases required more than one management strategy. $Complications with an incidence of 0% (e.g., hydrothorax, segmental atelectasis, esophageal stricture, submucosal fistula, atrial fibrillation, urinary retention, pleural effusion, mortality) are not listed for brevity
A total of 15 management events were undertaken to address these complications. The majority of cases (33.3%) were managed conservatively. Endoscopic intervention was successful in several instances, including clip closure (20.0%) and stent placement (13.3%). More invasive interventions were seldom needed, with one case each requiring chest tube insertion for pneumothorax, needle decompression for pneumoperitoneum, and a surgical approach involving mediastinal washout and perforation repair. There were no procedure-related mortalities.
Comparative analysis by time period
A comparative analysis was performed based on the timeline of the procedure, with 42 patients undergoing POEM before January 2020 and 63 patients from January 2020 onward [Table 3]. A significant difference was observed in the median hospital stay, which was shorter in the earlier cohort (1.0 day, IQR 1.0-3.0) compared to the later cohort (4.0 days, IQR 4.0-5.0; P < 0.001). A trend toward a higher clinical success rate was noted in the pre-2020 group (85.7% vs. 71.4%), though this difference did not reach statistical significance (P = 0.087).
Table 3.
Comparison of outcomes and complications before and after January 1, 2020 in patients undergoing peroral endoscopic myotomy (POEM)
| Variable | Overall (n=105) | Before 2020 (n=42) | From 2020 (n=63) | P |
|---|---|---|---|---|
| Hospital stay, days Median [IQR] | 3.0 [1.0, 5.0] | 1.0 [1.0, 3.0] | 4.0 [4.0, 5.0] | <0.0011 |
| Clinical success | 81 (77.1%) | 36 (85.7%) | 45 (71.4%) | 0.0872 |
| Any complication | 28 (26.7%) | 10 (23.8%) | 18 (28.6%) | 0.5922 |
| Procedure-related complications | ||||
| Postoperative leak (radiographic) | 6 (5.7%) | 4 (9.5%) | 2 (3.2%) | 0.2123 |
| Bleeding | 3 (2.9%) | 1 (2.4%) | 2 (3.2%) | 1.0003 |
| Mucosal ulceration | 1 (1.0%) | 1 (2.4%) | 0 (0.0%) | 0.3913 |
| Esophageal perforation | 2 (1.9%) | 2 (4.8%) | 0 (0.0%) | 0.1443 |
| Esophageal diverticulum | 1 (1.0%) | 1 (2.4%) | 0 (0.0%) | 0.3913 |
| Dehiscence of tunnel opening | 2 (1.9%) | 1 (2.4%) | 1 (1.6%) | 1.0003 |
| Gas-related events | ||||
| Subcutaneous emphysema | 12 (11.4%) | 3 (7.1%) | 9 (14.3%) | 0.3573 |
| Pneumoperitoneum | 14 (13.3%) | 4 (9.5%) | 10 (15.9%) | 0.4053 |
| Pneumomediastinum | 12 (11.4%) | 2 (4.8%) | 10 (15.9%) | 0.1083 |
| Pneumothorax | 5 (4.8%) | 2 (4.8%) | 3 (4.8%) | 1.0003 |
| Other outcomes | ||||
| Return to operating room | 2 (1.9%) | 1 (2.4%) | 1 (1.6%) | 1.0003 |
| Aspiration pneumonia | 1 (1.0%) | 0 (0.0%) | 1 (1.6%) | 1.0003 |
1Wilcoxon rank-sum test. 2Pearson’s Chi-squared test. 3Fisher’s exact test. Data are presented as n (%) unless otherwise specified. Complications with an incidence of 0 in both groups (e.g., hydrothorax, mortality) are omitted for brevity. IQR, interquartile range
The overall incidence of complications was comparable between the two time periods (23.8% before 2020 vs. 28.6% after 2020, P = 0.592). While the specific types of complications varied, no individual complication demonstrated a statistically significant difference in incidence between the two groups. Notably, there was a nonsignificant trend toward a higher rate of pneumomediastinum in the post-2020 cohort (15.9% vs. 4.8%, P = 0.108).
Predictors of clinical success
A univariate analysis was performed to identify factors associated with clinical success following POEM, comparing 81 successful cases to 24 cases of failure [Table 4]. No significant differences were identified in demographic, clinical, manometric, or procedural variables between the two groups. Notably, the rates of previous intervention were identical between those who failed and those who achieved success (25.0% vs. 25.9%, P = 0.928). Preoperative manometric metrics, including mean IRP (P = 0.844) and resting LES pressure (P = 0.165), were also not predictive of outcome.
Table 4.
Univariate analysis of factors associated with clinical success following peroral endoscopic myotomy (POEM)
| Variable | Overall (N=105) | Failure (N=24) | Success (N=81) | P |
|---|---|---|---|---|
| Demographics | ||||
| Age, years | 41.0 [29.0, 53.0] | 39.0 [31.4, 48.2] | 41.0 [29.0, 53.0] | 0.6771 |
| Female sex | 52 (49.5%) | 14 (58.3%) | 38 (46.9%) | 0.3272 |
| BMI, kg/m2 | 23.8 [20.2, 28.6] | 26.4 [20.2, 34.2] | 23.8 [20.2, 28.6] | 0.2161 |
| Clinical characteristics | ||||
| ASA Class | 0.2892 | |||
| 1 | 33 (31.4%) | 5 (20.8%) | 28 (34.6%) | |
| 2 | 58 (55.2%) | 14 (58.3%) | 44 (54.3%) | |
| 3 | 14 (13.3%) | 5 (20.8%) | 9 (11.1%) | |
| Type of achalasia | 0.3072 | |||
| Type 2 | 81 (77.1%) | 16 (66.7%) | 65 (80.2%) | |
| Type 1 | 11 (10.5%) | 3 (12.5%) | 8 (9.9%) | |
| Type 3 | 13 (12.4%) | 5 (20.8%) | 8 (9.9%) | |
| Disease duration, years | 2.0 [1.3, 5.3] | 3.5 [2.0, 6.0] | 2.0 [1.3, 5.3] | 0.2861 |
| Preoperative Eckardt score | 7.0 [5.0, 9.0] | 8.0 [6.0, 9.0] | 7.0 [5.0, 9.0] | 0.1571 |
| Previous intervention | 27 (25.7%) | 6 (25.0%) | 21 (25.9%) | 0.9282 |
| Manometry metrics | ||||
| Mean IRP, mm Hg (n=103) | 30.9 [23.8, 46.5] | 31.1 [27.6, 38.0] | 30.9 [23.8, 46.5] | 0.8441 |
| Resting LES pressure, mm Hg (n=104) | 39.7 [31.9, 51.3] | 46.8 [41.5, 60.7] | 39.7 [31.9, 51.3] | 0.1651 |
| Procedure details | ||||
| Myotomy length, cm (n=98) | 10.0 [9.0, 10.0] | 10.0 [9.0, 10.3] | 10.0 [9.0, 10.0] | 0.7931 |
| Tunnel length, cm (n=99) | 12.0 [12.0, 13.0] | 12.0 [12.0, 13.0] | 12.0 [12.0, 13.0] | 0.8041 |
| Mucosotomy distance, cm (n=92) | 10.0 [10.0, 10.0] | 10.0 [10.0, 10.0] | 10.0 [10.0, 10.0] | 0.1831 |
| Outcome | ||||
| Postoperative complication | 28 (26.7%) | 10 (41.7%) | 18 (22.2%) | 0.0582 |
1Wilcoxon rank-sum test. Data presented as Median [Interquartile Range] or n (%) as appropriate. 2Pearson’s Chi-squared test. The “Treatment of Post POEM failure” category was excluded from this analysis as it represents a consequence of the outcome (failure) rather than a potential predictor. IRP, integrated relaxation pressure; LES, lower esophageal sphincter
While not reaching formal statistical significance, a strong trend was observed for postoperative complications, which occurred more frequently in the failure group than in the success group (41.7% vs. 22.2%, P = 0.058). Similarly, a higher preoperative Eckardt score showed a nonsignificant association with treatment failure (P = 0.157).
Subsequent multivariable logistic regression analysis, adjusting for all potential predictors, confirmed that no variable was an independent predictor of clinical success [Table 5]. The occurrence of a postoperative complication (aOR 0.38, 95% CI 0.11-1.32, P = 0.129) and a higher preoperative Eckardt score (aOR 0.77 per 1-point increase, 95% CI 0.58-1.02, P = 0.068) remained the factors most strongly associated with a reduced odds of success, though these associations did not reach statistical significance.
Table 5.
Univariate and multivariable analysis of factors associated with clinical success following peroral endoscopic myotomy (POEM)
| Variable | Category | Univariate analysis success (n=81) | P | Multivariable analysis aOR | 95% CI | P |
|---|---|---|---|---|---|---|
| Demographics | ||||||
| Age | Per 1-year increase | 0.6771 | 1.01 | 0.96-1.06 | 0.601 | |
| Female sex | Female vs. Male | 38/81 (46.9%) | 0.3272 | 0.81 | 0.23-2.87 | 0.739 |
| BMI | Per 1-unit increase | 0.2161 | 0.93 | 0.85-1.02 | 0.140 | |
| Clinical characteristics | ||||||
| ASA Class | 0.2892 | |||||
| 1 | (Ref) | 28/81 (34.6%) | 1.00 | (Ref) | ||
| 2 | vs. ASA 1 | 44/81 (54.3%) | 0.76 | 0.18-3.10 | 0.697 | |
| 3 | vs. ASA 1 | 9/81 (11.1%) | 0.40 | 0.05-3.27 | 0.389 | |
| Type of achalasia | 0.3072 | |||||
| Type 2 | (Ref) | 65/81 (80.2%) | 1.00 | (Ref) | ||
| Type 1 | vs. Type 2 | 8/81 (9.9%) | 0.48 | 0.07-3.30 | 0.459 | |
| Type 3 | vs. Type 2 | 8/81 (9.9%) | 0.27 | 0.05-1.37 | 0.114 | |
| Disease duration | Per 1-year increase | 0.2861 | 1.03 | 0.89-1.20 | 0.674 | |
| Preop. Eckardt score | Per 1-point increase | 0.1571 | 0.77 | 0.58-1.02 | 0.068 | |
| Previous intervention | Yes vs. No | 21/81 (25.9%) | 0.9282 | 1.28 | 0.28-5.91 | 0.755 |
| Manometry metrics | ||||||
| Mean IRP, mm Hg | Per 1-mm Hg increase | 0.8441 | 1.02 | 0.97-1.08 | 0.484 | |
| Resting LES pressure, mm Hg | Per 1-mm Hg increase | 0.1651 | 0.98 | 0.94-1.02 | 0.280 | |
| Procedure details | ||||||
| Myotomy length, cm | Per 1-cm increase | 0.7931 | 1.22 | 0.72-2.10 | 0.460 | |
| Tunnel length, cm | Per 1-cm increase | 0.8041 | 1.10 | 0.53-2.28 | 0.795 | |
| Mucosotomy distance, cm | Per 1-cm increase | 0.1831 | 0.88 | 0.35-2.21 | 0.792 | |
| Outcome | ||||||
| Postoperative complication | Yes vs. No | 18/81 (22.2%) | 0.0582 | 0.38 | 0.11-1.32 | 0.129 |
| Intercept | 44.93 | 0.01-152, 387.72 | 0.359 |
1Wilcoxon rank-sum test. 2Pearson’s Chi-squared test. Model Fit (Multivariable): Deviance=76.1, AIC=110, McFadden’s R2=0.176. aOR, adjusted odds ratio; CI, confidence interval; IRP, integrated relaxation pressure; LES, lower esophageal sphincter; Ref, reference category
DISCUSSION
This single-center study demonstrates that POEM is a highly effective and safe therapeutic intervention for achalasia, with a clinical success rate of 77.1% and a significant improvement in Eckardt scores, corroborating its established role in the management of this challenging condition. Our findings align with the global body of evidence, where POEM has consistently shown success rates ranging from 82% to 94% in large series and meta-analyses.[4,25,26,27,28] The slightly lower success rate in our cohort may be attributed to the inclusion of patients with more complex profiles, including a significant proportion (25.7%) with prior failed interventions and a non-negligible rate of type III achalasia (12.4%), which can present technical challenges. The high patient satisfaction rate (69.5%) further underscores the procedure’s effectiveness from the patient’s perspective, a crucial metric in a chronic disorder like achalasia.
The safety profile of POEM in our study is consistent with international standards. The overall complication rate of 26.7% is within the widely reported range of 15–30%,[20,21,29] with the vast majority being minor, gas-related events (pneumoperitoneum, subcutaneous emphysema, pneumomediastinum) that are inherent to the procedure’s technique and were managed conservatively or with minimal intervention. The low rates of major adverse events, such as esophageal perforation (1.9%) and return to the operating room (1.9%), with zero mortality, reinforce the procedural safety when performed by experienced endoscopists at a high-volume center. The management strategies we employed, primarily conservative and endoscopic, were successful in resolving most issues, echoing the findings of other centers that the majority of POEM-related complications can be managed endoscopically without the need for surgery.[20,21,29]
A pivotal finding of our study is the significant objective GERD rate of 24.4% among tested patients, leading to 58.8% of our cohort being on PPI therapy at follow-up. This aligns with the known drawback of POEM as the procedure does not include an anti-reflux valve mechanism. Our rates are comparable to those reported in systematic reviews, where abnormal pH studies are found in 20–40% of patients post-POEM.[16,30,31] This highlights the critical importance of post-procedure monitoring for GERD and the need for a tailored, long-term management strategy for reflux in these patients.
Interestingly, our comparative analysis revealed a significant increase in hospital stay length in the later cohort, a finding that contrasts with the typical learning curve effect where efficiency improves over time. This may reflect a shift in institutional policy toward more cautious postoperative observation rather than a change in procedural technique or an increase in complication severity, which remained statistically unchanged. Furthermore, our multivariate analysis failed to identify any strong independent predictors of clinical success, a finding that is not uncommon in POEM literature.[32,33,34] The strong trends suggesting that postoperative complications and a higher preoperative Eckardt score may negatively impact success, while not statistically significant, provide valuable hypotheses for future, larger studies to investigate.
When compared to the recent multicenter Middle Eastern study by Al Lehibi et al., our findings, while confirming POEM as an effective and safe cornerstone treatment for achalasia in the region, reveal a lower clinical success rate (77.1% vs. 95.5%), potentially attributable to our larger, more complex cohort and longer study duration.[35] Although our overall complication rate was lower (26.7% vs. 35.8%), the profiles differed, with our study noting more pneumomediastinum and the multicenter study reporting more pneumoperitoneum; both studies, however, affirmed that most complications were minor. Critically, both works highlight the significant trade-off of post-POEM GERD, with our objective assessment finding reflux in 24.4% of tested patients leading to proactive PPI use in 58.8% of our cohort, reinforcing the consistent regional message of the procedure’s efficacy and manageable safety profile alongside the considerable risk of iatrogenic reflux that necessitates vigilant long-term management.[35]
Our study has limitations, including its single-center, retrospective design and the lack of universal objective GERD testing, which may underestimate the true incidence of reflux. However, its strengths include a substantial sample size, detailed characterization of complications and their management, and the provision of valuable real-world data from a tertiary care center, contributing to the global understanding of POEM outcomes.
In conclusion, our experience confirms that POEM is an effective and safe treatment for achalasia, with outcomes comparable to international benchmarks. The procedure significantly improves symptoms and patient satisfaction, albeit with a recognized risk of post-procedure GERD that requires vigilant management. The absence of clear preoperative predictors for success underscores the procedure’s broad applicability across different patient subtypes. Future prospective studies with longer follow-up are warranted to further refine patient selection criteria and optimize strategies for preventing and managing GERD.
Conflict of interest
There are no conflicts of interest.
Funding Statement
Nil.
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