Comparison of per-oral endoscopic myotomy and pneumatic dilation in the management of achalasia: Systematic review and meta-analysis

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Gastrointestinal Endoscopy


Background: Pneumatic dilation (PD) is a commonly used endoscopic treatment for achalasia but its efficacy is limited by high rate of recurrence of symptoms. PD is also associated with a small but significant risk of esophageal perforation. Per-oral endoscopic myotomy (POEM) is a relatively newer treatment option. POEM has been compared with PD in the management of achalasia. Aims: To compare the efficacy and safety of POEM and PD in the management of achalasia by systematic review and meta-analysis Methods: We reviewed Medline, Scopus, Web of Science and Cochrane databases from inception to September 2019 to identify observational studies and randomized controlled trials (RCTs) comparing POEM with PD in the management of achalasia. Our primary outcome of interest was clinical success defined by post-treatment Eckardt score ≤3. Secondary outcomes were adverse events, difference in post-treatment mean Eckardt score, integrated relaxation pressure (IRP) and basal lower esophageal sphincter pressure (LESP) between groups. Data were analyzed using a random effects model and summarized as pooled odds ratio (OR) with 95% CI for categorical variables and pooled standardized mean difference (SMD) with 95% CI for continuous variables. Heterogeneity was assessed by I2 statistic. Results: We included 6 observational studies and 1 RCT with 619 patients; 255 underwent POEM and 364 underwent PD. Main results are summarized in Table 1 and depicted graphically in Figure 1. POEM demonstrated better clinical success at 3 and 6 months and at 1, 2 and 3 years post-treatment compared to PD. Pooled OR (95% CI) for clinical success was 0.12 (0.06, 0.24) at 1 year and 0.15 (0.08, 0.28) at 2 years post-treatment (Figures 1A, 1B). Esophageal perforation occurred in 0/255 patients who received POEM and 4/364 who had PD. The most common adverse events with POEM were subcutaneous emphysema and new onset gastroesophageal reflux disease (GERD). Subcutaneous emphysema resolved spontaneously in all cases and did not require treatment. Risk of GERD was significantly higher with POEM; pooled OR 1.66 (1.20, 2.29). Mean pre-treatment Eckardt score was slightly higher in patients undergoing PD. Post-treatment Eckardt was lower with POEM; pooled SMD (95% CI) -0.312 (-0.488, -0.136). There was no difference in pre-treatment IRP or LESP between groups. Post-treatment IRP was lower with POEM than PD; pooled SMD -0.418 (-0.640, -0.195). Post-treatment LESP was also lower with POEM; pooled SMD -0.613 (-0.830, -0.395). All outcomes of interest had low heterogeneity except for post-treatment LESP (I2=90%), although this was reduced to 66% after excluding one study of patients aged 65 or older. Conclusions: POEM has better long-term outcomes than PD in the treatment of achalasia. PD is associated with a small risk of perforation. However, risk of new onset GERD is much higher with POEM than PD.





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