TY - JOUR
T1 - Is peroral endoscopic myotomy (POEM) more effective than pneumatic dilation and Heller myotomy? A systematic review and meta-analysis
AU - Dirks, Rebecca C.
AU - Kohn, Geoffrey P.
AU - Slater, Bethany
AU - Whiteside, Jake
AU - Rodriguez, Noe A.
AU - Docimo, Salvatore
AU - Pryor, Aurora
AU - Stefanidis, Dimitrios
AU - on behalf of the SAGES guidelines committee
PY - 2021/5
Y1 - 2021/5
N2 - 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.
AB - 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.
KW - Esophageal achalasia
KW - Heller myotomy
KW - Pneumatic dilation
KW - POEM
KW - Systematic review
UR - http://www.scopus.com/inward/record.url?scp=85100862907&partnerID=8YFLogxK
U2 - 10.1007/s00464-021-08353-w
DO - 10.1007/s00464-021-08353-w
M3 - Review Article
C2 - 33655443
AN - SCOPUS:85100862907
SN - 0930-2794
VL - 35
SP - 1949
EP - 1962
JO - Surgical Endoscopy
JF - Surgical Endoscopy
IS - 5
ER -