Is peroral endoscopic myotomy (POEM) more effective than pneumatic dilation and Heller myotomy? A systematic review and meta-analysis

Rebecca C. Dirks, Geoffrey P. Kohn, Bethany Slater, Jake Whiteside, Noe A. Rodriguez, Salvatore Docimo, Aurora Pryor, Dimitrios Stefanidis, on behalf of the SAGES guidelines committee

Research output: Contribution to journalReview ArticleResearchpeer-review

27 Citations (Scopus)

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.

Original languageEnglish
Pages (from-to)1949-1962
Number of pages14
JournalSurgical Endoscopy
Volume35
Issue number5
DOIs
Publication statusPublished - May 2021

Keywords

  • Esophageal achalasia
  • Heller myotomy
  • Pneumatic dilation
  • POEM
  • Systematic review

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