Long-term outcomes after per-oral endoscopic myotomy versus laparoscopic Heller myotomy in the treatment of achalasia: a systematic review and meta-analysis.

BACKGROUND

Achalasia is a rare, benign esophageal motility disorder. Laparoscopic Heller myotomy (LHM) is the gold standard treatment. Per-oral endoscopic myotomy (POEM) is an alternative endoscopic technique that has comparable short-term results to LHM. There are limited data on long-term results. We performed a systematic review and meta-analysis to evaluate longer-term outcomes in POEM compared to LHM for the treatment of achalasia.

METHODS

We searched EMBASE, Pubmed, Medline and CENTRAL databases through January 2024. We included primary double-arm studies in adult patients with follow-up periods of ≥ 24 months. The primary outcome was treatment success, defined as Eckardt score ≤ 3. Secondary outcomes were operation length, length of stay, postoperative complications and postoperative gastroesophageal reflux disease (GERD). Two authors independently reviewed studies, extracted data, and assessed quality of evidence using the Cochrane Risk-of-Bias tool for Randomized Trials Version 2 and the Risk of Bias in Nonrandomized Studies-of Intervention tool. Pooled estimates were calculated using random effects meta-analyses. Heterogeneity was quantified using the inconsistency statistic, and funnel plot was used to assess publication bias.

RESULTS

There were 9 studies included with 1099 patients; 583 underwent POEM with a mean follow-up length of 34.2 months. There was no difference in treatment success between POEM and LHM (OR 1.43; CI 0.96-2.13). POEM had a significantly shorter operative time (MD -35.69 min; CI -50.54-[- 20.83]), shorter length of stay (MD - 0.70 days; CI -1.03-[- 0.36]) and comparable incidence of complications (OR 0.80; CI 0.37-1.73). Meta-analysis showed a significantly increased risk of esophagitis with POEM when outlier studies were excluded (OR 2.57; CI 1.45-4.53]), though there was a greater odds of continued postoperative PPI use in POEM (OR 1.72; CI 1.03-2.89]).

CONCLUSION

POEM appears to have equivalent long-term efficacy to LHM, with possibly higher risk of postoperative GERD. More randomized studies are needed to examine outcomes beyond 2 years and to determine the long-term clinical significance of GERD following POEM.