What to Do When POEM Does Not Achieve Clinical Success in Type III Achalasia with High-Amplitude Spastic Contractions

Clinical Scenario

This protocol addresses patients with Type III achalasia — defined by high-amplitude spastic contractions in the esophageal body on high-resolution manometry — who have undergone initial treatment but have not reached the defined threshold for clinical success.

Previous Treatment — Insufficient Response

Initial management with peroral endoscopic myotomy (POEM) — the recommended first-line intervention for Type III achalasia — did not achieve the target outcome: an Eckardt score ≤3. This protocol defines the approach taken after that failure.

Next-Line Approach (partial overview)

Following failed initial myotomy, options involve either a pressure-based dilation procedure or a redo myotomy. The selection between approaches — and the specific technique — depends on clinical factors set out in the full structured regimen.

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References

DOI: 10.1016/j.gie.2019.04.231

Three achalasia subtypes have been defined based on the high-resolution manometry findings in the esophageal body: type I or classic achalasia with low intraesophageal pressure, type II with pan-esophageal pressurization, and type III with high-amplitude spastic contractions.

We suggest POEM as the preferred treatment for management of patients with type III achalasia.

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.

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