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Cleveland Clinic

Salvage Peroral Endoscopic Myotomy after Failed Heller Myotomy Fails to Match Index Therapy Outcomes

Strategic Insights

— 2 min read

Fresh data on the comparison of salvage peroral endoscopic myotomy (POEM) after failed Heller myotomy (HM) and index POEM for achalasia has been released. The study, conducted by Cleveland Clinic, found that salvage POEM provided durable palliation for recurrent achalasia symptoms following HM, but with less favorable outcomes than index POEM.

The researchers analyzed data from 381 patients who underwent POEM for achalasia at Cleveland Clinic between 2014 and 2023. The study found that 84 patients had prior HM (POEM-after-HM group) and 297 had not (index-POEM group). The study showed that longitudinal symptom palliation differed between the two groups, with 67% of the POEM-after-HM group and 80% of the index-POEM group having an Eckardt score of 3 at 5 years. Complete esophageal emptying at 5 years was 20% in the POEM-after-HM group vs. 24% in the index-POEM group.

The study concluded that salvage POEM provides durable palliation for recurrent achalasia symptoms following HM, but with less favorable outcomes than index POEM. Factors inherent to prior HM, such as fibrosis, narrow crural closure, and tight fundoplication, may limit salvage POEM effectiveness. The research has been peer-reviewed and published in The Journal of Thoracic and Cardiovascular Surgery.

Key Takeaways:

  • Salvage POEM after failed HM provides durable palliation for recurrent achalasia symptoms.
  • Longitudinal symptom palliation differed between the POEM-after-HM group and the index-POEM group, with 67% and 80% of patients, respectively, having an Eckardt score of 3 at 5 years.
  • Complete esophageal emptying at 5 years was 20% in the POEM-after-HM group vs. 24% in the index-POEM group.
  • Factors inherent to prior HM, such as fibrosis, narrow crural closure, and tight fundoplication, may limit salvage POEM effectiveness.
  • Prior fundoplication does not protect against post-POEM reflux esophagitis.
  • The study recommends closer follow-up for patients undergoing POEM after failed HM.
  • The study was conducted by a team of researchers from Cleveland Clinic, led by Nethra Jain, and included Andrew Conner, John Barron, Andrew J. Toth, Andrew Tang, Feredun Azari, Monisha Sudarshan, Sudish C. Murthy, Eugene H. Blackstone, and Siva Raja.

Statistics:

  • 381 patients underwent POEM for achalasia at Cleveland Clinic between 2014 and 2023.
  • 84 patients had prior HM (POEM-after-HM group) and 297 had not (index-POEM group).
  • 62 pairs of patients were propensity-score matched with median follow-up of 3 years.
  • Longitudinal symptom palliation differed between the two groups, with 67% and 80% of patients, respectively, having an Eckardt score of 3 at 5 years.
  • Complete esophageal emptying at 5 years was 20% in the POEM-after-HM group vs. 24% in the index-POEM group.
  • 10 reinterventions were performed following POEM-after-HM vs. 4 following index-POEM (P=0.24).
  • The study recommends closer follow-up for patients undergoing POEM after failed HM.

Sources:

  • The Journal of Thoracic and Cardiovascular Surgery, 2025
  • Mosby-elsevier, 360 Park Avenue South, New York, NY 10010-1710, USA
  • Cleveland Clinic, Dept. of Thoracic and Cardiovascular Surgery, Cleveland, OH
  • NewsRx. Study Data from Cleveland Clinic Update Knowledge of Esophagitis (When the Gold Standard Fails: Propensity-Matched Comparison of Peroral Endoscopic Myotomy after Heller Myotomy vs. Index Peroral Endoscopic Myotomy). Medical Devices & Surgical Technology Week. November 2, 2025; p 2186.

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