POEM vs laparoscopic Heller myotomy with fundoplication for achalasia: systematic review and meta-analysis of randomized and prospective studies.

BACKGROUND

Achalasia is definitively treated with peroral endoscopic myotomy (POEM) or laparoscopic Heller myotomy with fundoplication (LHM + PF), but reflux after POEM remains a key concern. We compared the safety and GERD outcomes of POEM and LHM + PF using randomized controlled trials and prospective comparative studies in treatment-naïve adults.

METHODS

We searched the MEDLINE, Embase, CENTRAL, Web of Science, and Scopus databases on October 18, 2025. Eligible studies directly compared POEM and LHM + PF in adults. The primary outcome was adverse events, and the secondary outcomes were endoscopic reflux esophagitis, abnormal 24-h pH, procedure time, and length of hospital stay. Random-effects meta-analyses were used to generate risk ratios (RRs) and mean differences (MDs). Certainty was graded using the GRADE system, and sensitivity and subgroup analyses were performed.

RESULTS

Four studies (three RCTs and one propensity-matched cohort; n = 590) met the inclusion criteria. Adverse events were similar (RR 1.15, 95% CI 0.38-3.44). POEM was associated with higher rates of endoscopic esophagitis (RR 3.10, 95% CI 2.17-4.41) and abnormal pH (RR 1.94, 95% CI 1.07-3.53) compared to LHM + PF. Procedure time did not differ significantly between groups (MD =  - 62.05 min, 95% CI - 180.78 to 56.67) with wide confidence intervals indicating imprecision. The length of hospital stay was comparable (MD = 0.32 days, 95% CI - 0.21 to 0.85).

CONCLUSION

In treatment-naïve adults, POEM and LHM + PF had comparable safety profiles and hospital stays. POEM is associated with higher reflux rates than LHM + PF. Both are viable options, and the selection should be individualized based on the patient's phenotype and institutional expertise.