Repeat Peroral Endoscopic Myotomy: Technical Difficulty and Risk Factors

Background and aims: Repeat peroral endoscopic myotomy (Re-POEM) appeared to be a promising salvage option for patients with persistent/recurrent symptoms after initial POEM, but it may be more technical challenging. Here we aim to evaluate the safety and technical difficulty of Re-POEM.

Methods: Between July 2012 and October 2023, 158 achalasia patients underwent Re-POEM were retrospectively enrolled. Another 2978 patients without prior myotomy were selected for naïve POEM. After propensity score matching (PSM), procedure-related parameters were compared between the two groups. Univariable and multivariable analyses were performed to reveal risk factors for difficult Re-POEM (defined as procedure time ≥ 90 min).

Results: With similar baseline characteristics between two groups after PSM, the procedure time was comparable between Re-POEM and naïve POEM groups (61.4±27.0 vs. 59.3±29.9, p=0.496). The Re-POEM group showed shorter esophageal myotomy length (7.0±2.1 vs. 8.2±1.1, p<0.001) and longer gastric myotomy length (2.3±0.6 vs. 2.1±0.4, p=0.017), compared with the naïve POEM group. Mucosal injury in Re-POEM group was slightly higher, which was not statistically significant (20.3% vs. 13.9%, p=0.135). No differences were found in the incidence of gas-related adverse events (AEs), major AEs, and technical difficulty. Multivariate analysis determined mucosal edema (OR=4.942, 95% CI, 1.554-15.714, p=0.007) and submucosal fibrosis (OR=3.817, 95% CI, 1.333-10.931, p=0.013) to be independent risk factors for difficult Re-POEM.

Conclusions: Re-POEM appears safe and feasible as a salvage option after initial POEM failure, with comparable procedure duration, incidence of AEs and technical difficulty to naïve POEM. Mucosal edema and submucosal fibrosis were associated with difficult Re-POEM.