Durability and reflux outcomes of peroral endoscopic myotomy compared to laparoscopic heller myotomy in achalasia: a meta-analysis of long-term studies.

BACKGROUND

Peroral endoscopic myotomy (POEM) has emerged as a minimally invasive alternative to laparoscopic Heller myotomy (LHM) for the treatment of achalasia. While short-term outcomes have been widely studied, evidence on long-term efficacy and safety remains limited and heterogeneous. This meta-analysis aimed to compare long-term clinical outcomes between POEM and LHM.

METHODS

We systematically searched PubMed, Embase, Scopus, Web of Science, and the Cochrane Library from inception to 15th August 2025. Studies were included if they directly compared POEM with LHM, reported outcomes with ≥2 years of follow-up, and provided data on operative time, length of hospital stay, functional outcomes, or reflux-related outcomes. Pooled mean differences (MDs) and odds ratios (ORs) with 95% confidence intervals (CIs) were calculated using random-effects models. Risk of bias was assessed using RoB 2 and Newcastle-Ottawa Scale.

RESULTS

A total of 10 studies involving 1158 patients (POEM = 609; LHM = 549) were included, comprising nine unique studies and one follow-up publication. POEM was associated with significantly shorter operative time (MD: -31.65 minutes, 95% CI: -46.39 to -16.92, P < 0.001) and shorter hospital stay (MD: -0.78 days, 95% CI: -1.40 to -0.52, P < 0.001). Functional outcomes, including dysphagia scores (MD: -0.24, 95% CI: -0.62 to 0.15, P = 0.23), postoperative Eckardt scores (MD: 0.11, 95% CI: -0.38 to 0.60, P = 0.65), and treatment success rates (OR: 1.43, 95% CI: 0.96 to 2.13, P = 0.08), were comparable between POEM and LHM at both 2-5 years and ≥ 5 years. Reflux-related outcomes, including RSI, GERD-HRQL, GERD symptoms, heartburn resolution, and incidence of esophagitis, did not significantly differ between groups. However, continued postoperative proton pump inhibitor (PPI) use was significantly more frequent after POEM (OR: 1.94, 95% CI: 1.35 to 2.78, P = 0.003).

CONCLUSION

Both POEM and LHM provide durable long-term relief of achalasia symptoms with comparable efficacy and reflux-related outcomes. POEM offers advantages in shorter operative time and hospital stay but is associated with a higher need for long-term PPI therapy. These findings support POEM as an effective long-term alternative to LHM, though further randomized studies with extended follow-up are warranted.