OA09.5. The Role of Laparoscopic Heller–Dor After Failed POEM or Pneumatic Dilatation: A Prospective Controlled Study

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Abstract Topic Benign Disease: Esophageal Surgery Background Over the last decade, peroral endoscopic myotomy (POEM) has become increasingly popular for treating esophageal achalasia (EA). However, symptoms persist or recur after POEM in 10%-20% of cases at middle-term follow-up. Currently, the treatment of POEM’s failures is supported only by small case series. The aim of this prospective, controlled study was to evaluate the outcome of laparoscopic Heller-Dor (LHD) in patients who previously underwent endoscopic treatment - POEM or pneumatic dilatation - as compared to treatment-naïve patients with EA. Methods Consecutive patients with a diagnosis of EA who underwent LHD between 2020-2025 were enrolled. The study population was divided in three groups: treatment-naïve patients (NA group), patients previously treated with an endoscopic myotomy (POEM group), and patients who had undergone pneumatic dilation (PD group). Symptoms were prospectively assessed using Eckard score (ES). Barium swallow, endoscopy and high resolution manometry (HRM) were performed before the treatment. Follow-up evaluations included: barium swallow at 1 month, HRM and 24h pH monitoring at 6 months, endoscopy at one year and every two years thereafter. The primary outcomes were morbidity, mortality, and therapeutic success. Secondary outcomes included postoperative IRP and post-procedural gastroesophageal reflux. Treatment failure was defined as the need for retreatment. Results The study involved 577 patients: 498 in the NA group, 15 in the POEM group and 64 in the PD group. No differences were seen in terms of LHD duration, length of myotomy and hospital stay. Intraoperative mucosal perforation occurred in 9 (1.8%) of the NA group, 2 (3.2%) of the PD group and no-one in the POEM group (p=0.65). No mortality was recorded. The median follow-up was 28 months. All patients had a reduction in the ES after LHD. A positive outcome was obtained in 98.6% of patients in the NA group, 95.3% in the PD group and 80% in the POEM group (p < 0.001). The postoperative median IRP was similar in all groups. After LHD, 24h pH-monitoring showed a higher incidence of abnormal postoperative acid exposure in the POEM group (p<0.01). Two post-POEM patients who relapsed after LHD were evaluated by EUS, which revealed abnormal esophageal wall fibrosis. Conclusion LHD appears to be safe but less effective for recurrent EA after POEM compared with naive and post-PD patients, although outcomes remain good in the mid-term. Further studies are necessary to clarify the mechanism of recurrence in these patients and improve treatment success.

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