S2183 Efficacy and Safety of Esophageal Peroral Endoscopic Myotomy (E-POEM) in Achalasia Patients With Cirrhosis: A Multicenter Study

Introduction: Achalasia affects about 10.8 per 100,000 individuals; its coexistence with cirrhosis remains undocumented. Portal hypertension and coagulopathy in cirrhosis pose bleeding and healing risks during peroral endoscopic myotomy (E-POEM). We conducted a multicenter retrospective study to assess E-POEM’s feasibility, technical success, outcomes, and safety in achalasia patients with cirrhosis. Methods: From 2020 to 2024, we retrospectively reviewed achalasia patients with cirrhosis undergoing E-POEM at 6 U.S. tertiary centers. We recorded demographics, cirrhosis etiology, variceal grade, procedural metrics, including myotomy length, orientation, tunnel extensions, and hospital stay. Continuous variables are presented as mean ± SD. The primary endpoint was technical success (completed myotomy without conversion or major bleeding); secondary endpoints included clinical success (Eckardt score ≤3 at 6 months) and adverse events. Results: Twenty-4 patients (mean age 67.5 ± 10.4 years; 10 women) underwent E-POEM. Etiologies included nonalcoholic steatohepatitis (n = 10), alcohol-related liver disease (n = 7) and viral hepatitis (n = 3). Mean MELD was 11.9 ± 6.2; 13 patients were Child–Pugh class A and 11 class B; 67% had prior decompensation. Baseline Eckardt score averaged 7.6 ± 2.1. All myotomies were successful; a posterior approach was used in 21 patients. Mean myotomy length was 11.4 ± 4.4 cm, extending 2.2 cm beyond the gastroesophageal junction; mean procedure time was 76.3 ± 37.9 minutes; mean hospital stay was 2.5 ± 4.2 days. Mean follow-up was 12.7 ± 7.6 months. One patient developed transient chest pain; 4 had extended stays for unrelated conditions. No variceal bleeds or transfusions occurred. Follow-up Eckardt scores were available for 21 patients, of whom 18 (85.7%) achieved clinical success. Conclusion: E-POEM is safe and effective in achalasia patients with compensated cirrhosis. These findings support its use in this high-risk group, but larger prospective studies are needed to confirm durability and refine selection criteria.