Peroral endoscopic myotomy for advanced achalasia with sigmoid-shaped esophagus: long-term outcomes from a prospective, single-center study

The sigmoid-shaped esophagus is considered to be the advanced stage of achalasia, in which the esophageal lumen is significantly dilated, swerved, and rotated. In consideration of the efficacy of peroral endoscopic myotomy (POEM) for early achalasia, it may also offer another option for the treatment of advanced achalasia with sigmoid-shaped esophagus. Our purpose was to evaluate the feasibility and long-term efficacy of POEM for patients with sigmoid-type achalasia. 32 consecutive patients with sigmoid-type achalasia (S1 type in 29 patients and S2 type in 3 patients) were prospectively included. Primary outcome was symptom relief during follow-up, defined as an Eckardt score a parts per thousand currency sign3. Secondary outcomes were procedure-related adverse events, the resting lower esophageal sphincter (LES) pressure, clinical reflux complications, and procedure-related parameters. All cases received POEM successfully. The mean operation time was 63.7 min (range 22-130 min). No serious complications related to POEM were encountered. During a mean follow-up period of 30.0 months (range 24-44 months), treatment success was achieved e in 96.8 % of cases (mean score pre- vs. post-treatment 7.8 vs. 1.4; P < 0.001). Mean LES pressure also decreased from a mean of 37.9 to 12.9 mmHg after POEM (P < 0.001). One patient experienced only partial symptom relief and additional balloon dilations were carried out to relief the symptoms twice. The overall clinical reflux complication rate of POEM for sigmoid-type achalasia was 25.8 %. The 2-year outcomes of POEM for advanced achalasia with sigmoid-shaped esophagus were excellent, resulting in long-term symptom relief in over 96 % cases and without serious complications. The morphological changes of esophagus may make subsequent endoscopic tunneling more challenging and time-consuming, but do not prevent successful POEM.