Is peroral endoscopic myotomy (POEM) more effective than pneumatic dilation and Heller myotomy? A systematic review and meta-analysis
- 2 March 2021
- journal article
- review article
- Published by Springer Science and Business Media LLC in Surgical Endoscopy
- Vol. 35 (5), 1949-1962
- https://doi.org/10.1007/s00464-021-08353-w
Abstract
Background Achalasia is a rare, chronic, and morbid condition with evolving treatment. Peroral endoscopic myotomy (POEM) has gained considerable popularity, but its comparative effectiveness is uncertain. We aim to evaluate the literature comparing POEM to Heller myotomy (HM) and pneumatic dilation (PD) for the treatment of achalasia. Methods We conducted a systematic review of comparative studies between POEM and HM or PD. A priori outcomes pertained to efficacy, perioperative metrics, and safety. Internal validity of observational studies and randomized trials (RCTs) was judged using the Newcastle Ottawa Scale and the Cochrane Risk of Bias 2.0 tool, respectively. Results From 1379 unique literature citations, we included 28 studies comparing POEM and HM (n = 21) or PD (n = 8), with only 1 RCT addressing each. Aside from two 4-year observational studies, POEM follow-up averaged ≤ 2 years. While POEM had similar efficacy to HM, POEM treated dysphagia better than PD both in an RCT (treatment “success” RR 1.71, 95% CI 1.34–2.17; 126 patients) and in observational studies (Eckardt score MD − 0.43, 95% CI − 0.71 to − 0.16; 5 studies; I2 21%; 405 patients). POEM needed reintervention less than PD in an RCT (RR 0.19, 95% CI 0.08–0.47; 126 patients) and HM in an observational study (RR 0.33, 95% CI 0.16, 0.68; 98 patients). Though 6–12 months patient-reported reflux was worse than PD in 3 observational studies (RR 2.67, 95% CI 1.02–7.00; I2 0%; 164 patients), post-intervention reflux was inconsistently measured and not statistically different in measures ≥ 1 year. POEM had similar safety outcomes to both HM and PD, including treatment-related serious adverse events. Conclusions POEM has similar outcomes to HM and greater efficacy than PD. Reflux remains a critical outcome with unknown long-term clinical significance due to insufficient data and inconsistent reporting.Keywords
This publication has 58 references indexed in Scilit:
- Achalasia: A review of clinical diagnosis, epidemiology, treatment and outcomesWorld Journal of Gastroenterology, 2013
- SAGES guidelines for the surgical treatment of esophageal achalasiaSurgical Endoscopy, 2011
- Treatment and surveillance strategies in achalasia: an updateNature Reviews Gastroenterology & Hepatology, 2011
- Achalasia: incidence, prevalence and survival. A population‐based studyNeurogastroenterology & Motility, 2010
- The Cost of Achalasia: Quantifying the Effect of Symptomatic Disease on Patient Cost Burden, Treatment Time, and Work ProductivitySurgical Innovation, 2010
- Peroral endoscopic myotomy (POEM) for esophageal achalasiaEndoscopy, 2010
- Effect of Immunoglobulin Therapy on the Rate of Infections in Multiple Myeloma Patients Undergoing Autologous Stem Cell Transplantation and or treated with immunomodulatory agentsMediterranean Journal of Hematology and Infectious Diseases, 2010
- The development of the GERD-HRQL symptom severity instrumentDiseases of the Esophagus, 2007
- Review article: the management of achalasia – a comparison of different treatment modalities1Alimentary Pharmacology & Therapeutics, 2006
- Heller's contribution to the surgical treatment of achalasia of the esophagusThe Annals of Thoracic Surgery, 1989