Systematic review and meta‐analysis: Efficacy and safety of POEM for achalasia

Abstract

Background: Peroral endoscopic esophageal myotomy (POEM) represents a less invasive alternative, as compared with conventional laparoscopic Heller myotomy for treating achalasia patients. In the last years, a number of prospective and retrospective experiences with POEM use for achalasia have been published. Methods: Relevant publications in which patients affected by achalasia underwent POEM treatment were identified by PubMed databases for the period 2010 -2013. From each study, we extracted the number and type of major complications (defined as those requiring any additional medical or surgical intervention). Data were pooled, using random-effects models. Heterogeneity among studies was assessed by using Cochran's Q and the I 2 statistic. Results: We found 16 studies that provided data on 551 patients. The median surveillance period was 6 months (range: 3-12). The median of mean POEM duration was 156 minutes (range: 42-112). Median myotomy length was 10 cm (range: 6-14). Technical and clinical success were reported in 97% (95% CI: 94-98%) and 93% (407/428; 95% CI: 90-95%). No heterogeneity (I 2 ¼ 0%) or publication bias was present in both estimates. When limiting the analysis only to adverse events that require medical or surgical interventions, major adverse events occurred in 14% (95% CI: 11-17%); however, only one patient needed post-POEM surgery (0.2%; 95% CI: 0-0.5%). Conclusions: POEM appeared to be a highly feasible and effective endoscopic treatment for achalasia. Despite POEM being apparently associated with relatively high morbidity, most patients are successfully managed conservatively, so that POEM appears as a very safe procedure; however, POEM should only be performed in centers able to treat POEM complications, such as pneumothorax or pneumoperitoneum.

Complications of submucosal endoscopy

“…The risk factors for major adverse events were short experience with the technique (<1 year), air insufflation, and mucosal edema. The results of this study are consistent with those reported in the literature [3,4,31]; also, this study confirmed that the use of CO 2 dramatically decreases the risk of complications.…”

“…Mucosal injuries have been reported during POEM in 0.3%e9% of the cases and mostly in early studies, as reported by two recent reviews [2,3]. Mucosal injuries represent the most feared type of complication, due to a hypothetic risk of fistulas, mediastinitis or peritonitis, especially when occurring in the EJ junction or cardia, areas in which these injuries are considered as authentic perforations.…”

“…The post-operative complications are represented by leakage of the suture, bleeding (ulcer or tunnel hematoma), and cardial ulceration. The most common delayed adverse event is gastro-esophageal reflux, occurring in 20%e30% of the patients [2,3,19]. Generally, the identified risk factors for technical difficulties in POEM were: short experience with the technique, sigmoid-type esophagus, and short tunnels (<3 cm) [2,19,24e26].…”

“…Finally, a myotomy is performed and the mucosal entry is closed with endoclips. The technical success of esophageal POEM reported in the literature is between 90% and 100%, and the clinical success is between 82% and 100% for the treatment of achalasia [3]. The results are reported in Table 1.…”

POEM and the management of achalasia

“…The safety profile of POEM is presumed to be at least comparable to LHM or PD 10 11. In a large retrospective analysis of 1680 patients over 5 years, only 55 patients (3.3%) experienced major adverse incidents (mAEs) including delayed mucosal barrier failure (0.8%), delayed bleeding (0.2%), hydrothorax (0.5%) and pneumothorax (1.5%).…”