Achalasia management with per-oral endoscopic myotomy: A study of clinical success and complications at a tertiary center in Saudi Arabia

Background: Per-oral endoscopic myotomy (POEM) has emerged as a minimally invasive treatment for achalasia, with growing global adoption. However, regional data from Saudi Arabia are scarce. This study aimed to evaluate the efficacy, safety, and long-term outcomes of POEM in a tertiary referral center in Riyadh. Methods: We conducted a retrospective cohort study of all consecutive patients with achalasia who underwent POEM at King Faisal Specialist Hospital and Research Centre between April 2017 and October 2023. Diagnosis was confirmed by high-resolution manometry and classified using the Chicago Classification v3.0 or v4.0. Clinical success was defined as an Eckardt score ≤3 at follow-up. Secondary outcomes included adverse events, gastroesophageal reflux disease (GERD), and need for further intervention. Results: A total of 105 patients (mean age 41.2 ± 13.9 years; 50.5% male) underwent POEM. The majority had type II achalasia (77.1%), followed by type III (12.4%) and type I (10.5%). Prior interventions were recorded in 25.7% of patients. Clinical success was achieved in 77.1%, with a significant reduction in mean Eckardt score (6.8 ± 2.3 to 1.8 ± 1.7; P < 0.001). The median follow-up was 1118 days. Patient satisfaction (≥80% symptom relief) was 69.5%. Complications occurred in 26.7%, predominantly gas-related events, with no procedure-related mortality. Major adverse events were rare (perforation 1.9%, reoperation 1.9%). Post-POEM GERD was confirmed in 24.4% of those tested with the Ph study, and 58.8% required proton pump inhibitor therapy at follow-up. Comparative analysis across time periods showed no significant difference in complication rates, although hospital stay was longer in the later cohort. Multivariable analysis did not identify independent predictors of clinical success. Conclusion: POEM is a safe and effective treatment for achalasia in Saudi Arabia, achieving substantial symptom relief with acceptable complication rates, consistent with international experience. The notable incidence of post-procedure GERD underscores the need for long-term reflux monitoring and management.