Achalasia After Failed Initial Myotomy, POEM, or Pneumatic Dilation

This protocol addresses achalasia that has not responded adequately to a first-line definitive intervention. When initial treatment does not produce the required clinical result, a structured next-line strategy is indicated.

Previous Treatment — Target Not Reached

Initial definitive therapy — laparoscopic Heller myotomy, pneumatic dilation, or peroral endoscopic myotomy (POEM) — did not achieve clinical success. The failure criterion is an Eckardt score above 3, reflecting persistent or inadequately reduced dysphagia, regurgitation, chest pain, or weight loss.

Treatment Target

Clinical success defined by an Eckardt score ≤3.

Next-Line Approach

When the initial procedure has not reached the Eckardt target, the evidence-based approach involves either a re-intervention with a dilation technique or a repeat surgical procedure — the specific choice and criteria are set out in the full protocol.

References

In patients with failed initial myotomy (POEM or laparoscopic Heller myotomy), we suggest pneumatic dilation or redo myotomy using either the same or an alternative myotomy technique (POEM or laparoscopic Heller myotomy).
The Eckardt score is based on the summation of 4 symptoms (dysphagia, regurgitation, chest pain, weight loss) that are graded according to severity, and treatment success is defined as a score ≤3.

DOI: 10.1016/j.gie.2019.04.231

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