Peroral (Poem) or Surgical Myotomy for the Treatment of Achalasia: A Systematic Review and Meta-Analysis

Abstract

BACKGROUND: Achalasia is a neurodegenerative motility esophageal disorder characterized by failure of lower esophageal sphincter relaxation. The conventional treatment option for achalasia has been laparoscopic Heller myotomy (LHM). However, in 2010, Inoue et al. described peroral endoscopic myotomy (POEM), a minimally invasive procedure, as an alternative therapy. To date, some studies with small sample sizes have aimed to compare outcomes of LHM vs POEM. OBJECTIVE: Thus, the aim of this study is to perform a systematic review and meta-analysis to better evaluate the efficacy and safety of these two techniques. METHODS: Individualized search strategies were developed from inception through April 2019 in accordance with PRISMA guidelines. Variables analyzed included operative time, overall adverse events rate, post-procedure gastroesophageal reflux disease (GERD), hospitalization length, post-procedure pain score, and Eckardt Score reduction. RESULTS: Twelve cohort trials were selected, consisting of 893 patients (359 in POEM group and 534 in LHM.) No randomized clinical trials were available. There was no difference in operative time (MD= -10,26, 95% CI (-5,6 to 8,2), P<0.001) or Post-Operative Gastroesophageal Reflux (RD: -0.00, 95%CI: (-0.09, 0.09), I2: 0%). There was decreased length of hospital stay for POEM (MD: -0.6, 95% CI (-1.11, -0.09), P=0.02), and an increased mean reduction in Eckardt score in POEM patients (MD = -0.257, 95% CI: (-0.512 to -0.002), P=0.048), with similar rates of adverse events. CONCLUSION: POEM demonstrated similar results compared to laparoscopic Heller myotomy with regards to improvement of dysphagia, post-procedure reflux, and surgical time, with the benefit of shorter length of hospital stay. Therefore, POEM can be considered an option for patients with achalasia.

Endoscopic Submucosal Dissection With Circumferential Incision Versus Tunneling Method for Treatment of Superficial Esophageal Cancer

“…ESD-T was carried out in our institution between 2009 and 2012 but can be considered as an emerging technique. Mastery of the technique is important as the use of the submucosal space for tunnel dissection has been proven to be effective for the treatment of large and even circumferential superficial lesions of the esophagus, peroral endoscopic myotomy (POEM), resection of subepithelial tumors and perhaps in the near future will enable interventions outside the gastrointestinal tract, including lymph node resection and removal of benign tumors in the mediastinum or abdominal cavity (31)(32)(33) . Modifications to ESD-T, including the performance of more than one submucosal tunnel have been described for more extensive and circumferential lesions (34)(35)(36)(37) .…”

Peroral endoscopic myotomy (POEM) is more cost-effective than laparoscopic Heller myotomy in the short term for achalasia: economic evaluation from a randomized controlled trial

“…Inoue et al 15 introduced the concept of natural orifice transluminal endoscopic surgery (NOTES) 16 17 associated with submucosal dissection 18 and named this technique peroral endoscopic myotomy (POEM). Studies have shown that the short- to mid-term efficacy of POEM is greater than 90 % and that the procedure is associated with less postoperative pain 19 20 21 22 23 24 25 . However, this procedure is frequently associated with some common adverse effects, such as pneumoperitoneum and surgical emphysema 26 .…”

Type II achalasia. What can be hidden behind panesophageal pressurization?

“…На сегодняшний день многочисленными исследованиями показаны сравнительный анализ безопасности, эффективности и отдаленных результатов того или иного способа миотомии при разных манометрических типах ахалазии [6,7]. Второй манометрический тип самый распространенный тип ахалазии пищевода [8].…”