Efficacy and Safety of Repeat Per-oral Endoscopic Myotomy After Failed POEM for Achalasia: A Systematic Review and meta-analysis.

Background: Per-oral endoscopic myotomy (POEM) is an effective option for treating achalasia. Despite its high efficacy, a fraction of patients remain symptomatic after POEM, and the data on the optimal management of these patients is limited. Few studies have evaluated the effectiveness of repeat POEM after a failed POEM.

Aim: To evaluate the efficacy and safety of repeat POEM for persistent symptoms after the initial POEM.

Methods: We searched major databases from inception to April 2024 to identify studies evaluating the efficacy and safety of repeat POEM after failed POEM in patients with achalasia. Our outcomes of interest were clinical success (a reduction in the Eckardt score to ≤3 after the procedure), adverse events, and differences in pre-procedure and post-procedure Eckardt scores. Using the random effects model, we calculated pooled rates with 95% CI for categorical variables and mean difference (MD) with 95% CI for continuous variables.

Results: We included 6 observational studies with 123 patients. The mean time between myotomies ranged from 12.2 to 13.5 months. The pooled rate (95% CI) of clinical success was 82.69% (95% CI; 69.65%-93.06%). The pooled rate (95% CI) of adverse events was 17.97% (95% CI: 5.08%-35.15%). The pooled mean±SD post-procedure Eckardt score was 1.63±1.93. The mean post-procedure Eckardt score was significantly lower than the re-procedure Eckardt score, MD (95% CI): 3.68 (2.58, 4.78).

Conclusion: Repeated POEM is an effective option for persistent symptoms of achalasia after initial POEM; however, it is associated with nontrivial adverse events.