Laparoscopic Heller–Dor as salvage therapy after failed POEM: a prospective comparative study

Objectives: Current therapeutic options for esophageal achalasia (EA) include pneumatic dilation (PD), laparoscopic Heller-Dor myotomy (LHD), and peroral endoscopic myotomy (POEM), which has gained increasing popularity over the last decade. However, symptoms persist or recur after POEM in 10-20% of cases. Evidence on management of POEM failures is limited to small case series. This study evaluates the outcome of LHD in patients who previously underwent endoscopic treatment-POEM or PD-as compared to treatment-naïve patients. Methods: Consecutive patients with EA who underwent LHD between 2020 and 2025 were prospectively recorded. The study population was divided in three groups: treatment-naïve (NA group), prior POEM (POEM group), and prior PD (PD group). Primary outcomes were morbidity, mortality, and therapeutic success. Secondary outcomes included postoperative IRP and postprocedural reflux. Treatment failure was defined as the persistence or reoccurrence of an Eckardt score > 3 or the need for retreatment. Results: A total of 577 patients were included: 498 in the NA group, 15 in the POEM group and 64 in the PD group. Intraoperative mucosal perforation occurred similarly (p = 0.65). No mortality was recorded. The median follow-up was 30 months (IQR: 22-34). Treatment success was significantly lower after prior POEM (80%) compared with naïve (98.6%) and PD group (95.3%) (p < 0.001). Abnormal postoperative acid exposure was more frequent after prior POEM (33.3%) (p < 0.01). In selected patients with recurrence, endoscopic ultrasound revealed marked esophageal wall fibrosis. Conclusions: LHD is safe and effective even after failed endoscopic therapy. However, patients previously treated with POEM represent a higher-risk subgroup with lower success rates and increased reflux.