Trans-segmental POEM in the management of esophageal asymmetry in achalasia: short outcomes from a retrospective, single-center study

1. Background and study aims: Esophageal asymmetry has been observed in some patients with achalasia, presenting as functional or structural alterations. This study aims to report a single-center experience with the trans-segmental peroral endoscopic myotomy (T-POEM) procedure for the management of esophageal asymmetry in achalasia. 2. Patients and methods: 22 patients with achalasia and severe dysphagia were included. Esophageal asymmetry and restrictive segments were assessed using the Eckardt score, HRM, barium esophagography, CT, EUS, and endoscopy. T-POEM was performed with targeted myotomy of tortuous segments, areas of localized muscular thickening, and localized restrictive muscular segments. This study evaluated the technical feasibility, safety, and observed short-term outcomes of T-POEM. 3. Results: T-POEM was technically successful in all 22 patients (100%), with a mean procedure time of 67 minutes. Three patients (13.6%) experienced documented periprocedural adverse events: one developed pneumothorax with fever, and two experienced transient retrosternal pain. All three events resolved with conservative treatment, and no event required endoscopic or surgical intervention or intensive care. Clinical success, defined as an Eckardt score ≤3 at the latest available follow-up, was observed in all 22 patients. The mean Eckardt score decreased from 6.7 to 1.3 (P < 0.0001) during the available short-term follow-up. 4. Conclusion: In this small retrospective case series, T-POEM was technically feasible and was associated with short-term symptom improvement in selected patients with complex achalasia and marked esophageal asymmetry. These preliminary findings do not establish superiority over existing POEM techniques and require confirmation in larger prospective comparative studies.