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Surgical Endoscopy
Published in: Surgical Endoscopy 5/2021

01-05-2021 | Esophagitis | SAGES Review Article

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

Authors: 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

Published in: Surgical Endoscopy | Issue 5/2021

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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.
Appendix
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Literature
1.
O’Neill OM, Johnston BT, Coleman HG (2013) Achalasia: a review of clinical diagnosis, epidemiology, treatment and outcomes. World J Gastroenterol 19:5806–5812PubMedPubMedCentral
2.
Sadowski DC, Ackah F, Jiang B, Svenson LW (2010) Achalasia: incidence, prevalence and survival. A population-based study. Neurogastroenterol Motil 22:e256–e261PubMed
3.
Nenshi R, Takata J, Stegienko S, Jacob B, Kortan P, Deitel W, Laporte A, Darling G, Urbach DR (2010) The cost of achalasia: quantifying the effect of symptomatic disease on patient cost burden, treatment time, and work productivity. Surg Innov 17:291–294PubMed
4.
Eckardt VF, Gockel I, Bernhard G (2004) Pneumatic dilation for achalasia: late results of a prospective follow up investigation. Gut 53:629–633PubMedPubMedCentral
5.
Lake JM, Wong RK (2006) Review article: the management of achalasia—a comparison of different treatment modalities. Aliment Pharmacol Ther 24:909–918PubMed
6.
Stefanidis D, Richardson W, Farrell TM, Kohn GP, Augenstein V, Fanelli RD (2012) SAGES guidelines for the surgical treatment of esophageal achalasia. Surg Endosc 26:296–311PubMed
7.
Payne WS (1989) Heller’s contribution to the surgical treatment of achalasia of the esophagus. 1914. Ann Thorac Surg 48:876–881PubMed
8.
Inoue H, Minami H, Kobayashi Y, Sato Y, Kaga M, Suzuki M, Satodate H, Odaka N, Itoh H, Kudo S (2010) Peroral endoscopic myotomy (POEM) for esophageal achalasia. Endoscopy 42:265–271PubMed
9.
Tuason J, Inoue H (2017) Current status of achalasia management: a review on diagnosis and treatment. J Gastroenterol 52:401–406PubMed
10.
11.
Higgins JPT, Thomas J, Chandler J, Cumpston M, Li T, Page MJ, Welch VA (eds) (2019) Cochrane handbook for systematic reviews of interventions version 6.0 (updated July 2019). Cochrane, 2019. Available from www.​training.​cochrane.​org/​handbook
12.
Moher D, Liberati A, Tetzlaff J, Altman DG, Group P (2009) Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. BMJ 339:b2535PubMedPubMedCentral
13.
Cumpston M, Chandler J (2019) Chapter IV: Updating a review. In: Higgins JPT, Thomas J, Chandler J, Cumpston M, Li T, Page MJ, Welch VA (eds) Cochrane handbook for systematic reviews of interventions version 6.0 (updated August 2019). Cochrane, 2019. Available from www.​training.​cochrane.​org/​handbook
14.
15.
Sterne JAC, Savovic J, Page MJ, Elbers RG, Blencowe NS, Boutron I, Cates CJ, Cheng HY, Corbett MS, Eldridge SM, Emberson JR, Hernan MA, Hopewell S, Hrobjartsson A, Junqueira DR, Juni P, Kirkham JJ, Lasserson T, Li T, McAleenan A, Reeves BC, Shepperd S, Shrier I, Stewart LA, Tilling K, White IR, Whiting PF, Higgins JPT (2019) RoB 2: a revised tool for assessing risk of bias in randomised trials. BMJ 366:l4898PubMed
16.
Review Manager (RevMan) (2014) The Nordic Cochrane Centre, The Cochrane Collaboration, Copenhagen
17.
Schünemann H, Brożek J, Guyatt G, Oxman A (eds) (2013) GRADE handbook for grading quality of evidence and strength of recommendations. Updated October 2013. The GRADE Working Group, 2013. Available from guidelinedevelopment.org/handbook
18.
Sanaka MR, Hayat U, Thota PN, Jegadeesan R, Ray M, Gabbard SL, Wadhwa N, Lopez R, Baker ME, Murthy S, Raja S (2016) Efficacy of peroral endoscopic myotomy vs other achalasia treatments in improving esophageal function. World J Gastroenterol 22:4918–4925PubMedPubMedCentral
19.
Peng L, Tian S, Du C, Yuan Z, Guo M, Lu L (2017) Outcome of peroral endoscopic myotomy (POEM) for treating achalasia compared with laparoscopic Heller myotomy (LHM). Surg Laparosc Endosc Percutan Tech 27:60–64PubMed
20.
Podboy AJ, Hwang JH, Rivas H, Azagury D, Hawn M, Lau J, Kamal A, Friedland S, Triadafilopoulos G, Zikos T, Clarke JO (2020) Long-term outcomes of per-oral endoscopic myotomy compared to laparoscopic Heller myotomy for achalasia: a single-center experience. Surg Endosc 35:792–801PubMed
21.
Tan Y, Zhu H, Li C, Chu Y, Huo J, Liu D (2016) Comparison of peroral endoscopic myotomy and endoscopic balloon dilation for primary treatment of pediatric achalasia. J Pediatr Surg 51:1613–1618PubMed
22.
Caldaro T, Familiari P, Romeo EF, Gigante G, Marchese M, Contini AC, Federici di Abriola G, Cucchiara S, De Angelis P, Torroni F, Dall’Oglio L, Costamagna G (2015) Treatment of esophageal achalasia in children: today and tomorrow. J Pediatr Surg 50:726–730PubMed
23.
Hungness ES, Teitelbaum EN, Santos BF, Arafat FO, Pandolfino JE, Kahrilas PJ, Soper NJ (2013) Comparison of perioperative outcomes between peroral esophageal myotomy (POEM) and laparoscopic Heller myotomy. J Gastrointest Surg 17:228–235PubMed
24.
Zheng Z, Zhao C, Su S, Fan X, Zhao W, Wang B, Jin H, Zhang L, Wang T, Wang B (2019) Peroral endoscopic myotomy versus pneumatic dilation—result from a retrospective study with 1-year follow-up. Z Gastroenterol 57:304–311PubMed
25.
Kumbhari V, Tieu AH, Onimaru M, El Zein MH, Teitelbaum EN, Ujiki MB, Gitelis ME, Modayil RJ, Hungness ES, Stavropoulos SN, Shiwaku H, Kunda R, Chiu P, Saxena P, Messallam AA, Inoue H, Khashab MA (2015) Peroral endoscopic myotomy (POEM) vs laparoscopic Heller myotomy (LHM) for the treatment of Type III achalasia in 75 patients: a multicenter comparative study. Endosc Int Open 3:E195–E201PubMedPubMedCentral
26.
Bhayani NH, Kurian AA, Dunst CM, Sharata AM, Rieder E, Swanstrom LL (2014) A comparative study on comprehensive, objective outcomes of laparoscopic Heller myotomy with per-oral endoscopic myotomy (POEM) for achalasia. Ann Surg 259:1098–1103PubMed
27.
de Pascale S, Repici A, Puccetti F, Carlani E, Rosati R, Fumagalli U (2017) Peroral endoscopic myotomy versus surgical myotomy for primary achalasia: single-center, retrospective analysis of 74 patients. Dis Esophagus 30:1–7PubMed
28.
Fumagalli U, Rosati R, De Pascale S, Porta M, Carlani E, Pestalozza A, Repici A (2016) Repeated surgical or endoscopic myotomy for recurrent dysphagia in patients after previous myotomy for achalasia. J Gastrointest Surg 20:494–499PubMed
29.
Greenleaf EK, Winder JS, Hollenbeak CS, Haluck RS, Mathew A, Pauli EM (2018) Cost-effectiveness of per oral endoscopic myotomy relative to laparoscopic Heller myotomy for the treatment of achalasia. Surg Endosc 32:39–45PubMed
30.
Hanna AN, Datta J, Ginzberg S, Dasher K, Ginsberg GG, Dempsey DT (2018) Laparoscopic Heller myotomy vs per oral endoscopic myotomy: patient-reported outcomes at a single institution. J Am Coll Surg 226(26):465-472e461PubMed
31.
Khashab MA, Kumbhari V, Tieu AH, El Zein MH, Ismail A, Ngamruengphong S, Singh VK, Kalloo AN, Clarke JO, Stein EM (2017) Peroral endoscopic myotomy achieves similar clinical response but incurs lesser charges compared to robotic heller myotomy. Saudi J Gastroenterol 23:91–96PubMedPubMedCentral
32.
Kim GH, Jung KW, Jung HY, Kim MJ, Na HK, Ahn JY, Lee JH, Kim DH, Choi KD, Song HJ, Lee GH (2019) Superior clinical outcomes of peroral endoscopic myotomy compared with balloon dilation in all achalasia subtypes. J Gastroenterol Hepatol 34:659–665PubMed
33.
Kumagai K, Tsai JA, Thorell A, Lundell L, Hakanson B (2015) Per-oral endoscopic myotomy for achalasia. Are results comparable to laparoscopic Heller myotomy? Scand J Gastroenterol 50:505–512PubMed
34.
Leeds SG, Burdick JS, Ogola GO, Ontiveros E (2017) Comparison of outcomes of laparoscopic Heller myotomy versus per-oral endoscopic myotomy for management of achalasia. Proc (Bayl Univ Med Cent) 30:419–423
35.
Meng F, Li P, Wang Y, Ji M, Wu Y, Yu L, Niu Y, Lv F, Li W, Li W, Zhai H, Wu S, Zhang S (2017) Peroral endoscopic myotomy compared with pneumatic dilation for newly diagnosed achalasia. Surg Endosc 31:4665–4672PubMed
36.
Miller HJ, Neupane R, Fayezizadeh M, Majumder A, Marks JM (2017) POEM is a cost-effective procedure: cost-utility analysis of endoscopic and surgical treatment options in the management of achalasia. Surg Endosc 31:1636–1642PubMed
37.
Ponds FA, Fockens P, Lei A, Neuhaus H, Beyna T, Kandler J, Frieling T, Chiu PWY, Wu JCY, Wong VWY, Costamagna G, Familiari P, Kahrilas PJ, Pandolfino JE, Smout A, Bredenoord AJ (2019) Effect of peroral endoscopic myotomy vs pneumatic dilation on symptom severity and treatment outcomes among treatment-naive patients with achalasia: a randomized clinical trial. JAMA 322:134–144PubMedPubMedCentral
38.
Ramirez M, Zubieta C, Ciotola F, Amenabar A, Badaloni A, Nachman F, Nieponice A (2018) Per oral endoscopic myotomy vs. laparoscopic Heller myotomy, does gastric extension length matter? Surg Endosc 32:282–288PubMed
39.
Sanaka MR, Thota PN, Parikh MP, Hayat U, Gupta NM, Gabbard S, Lopez R, Murthy S, Raja S (2019) Peroral endoscopic myotomy leads to higher rates of abnormal esophageal acid exposure than laparoscopic Heller myotomy in achalasia. Surg Endosc 33:2284–2292PubMed
40.
Schneider AM, Louie BE, Warren HF, Farivar AS, Schembre DB, Aye RW (2016) A matched comparison of per oral endoscopic myotomy to laparoscopic Heller myotomy in the treatment of achalasia. J Gastrointest Surg 20:1789–1796PubMed
41.
Ujiki MB, Yetasook AK, Zapf M, Linn JG, Carbray JM, Denham W (2013) Peroral endoscopic myotomy: a short-term comparison with the standard laparoscopic approach. Surgery 154:893–897 (discussion 897–900)PubMed
42.
Wang X, Tan Y, Lv L, Zhu H, Chu Y, Li C, Liu D (2016) Peroral endoscopic myotomy versus pneumatic dilation for achalasia in patients aged ≥ 65 years. Rev Esp Enferm Dig 108:637–641PubMed
43.
Ward MA, Gitelis M, Patel L, Vigneswaran Y, Carbray J, Ujiki MB (2017) Outcomes in patients with over 1-year follow-up after peroral endoscopic myotomy (POEM). Surg Endosc 31:1550–1557PubMed
44.
Werner YB, Hakanson B, Martinek J, Repici A, von Rahden BHA, Bredenoord AJ, Bisschops R, Messmann H, Vollberg MC, Noder T, Kersten JF, Mann O, Izbicki J, Pazdro A, Fumagalli U, Rosati R, Germer CT, Schijven MP, Emmermann A, von Renteln D, Fockens P, Boeckxstaens G, Rosch T (2019) Endoscopic or surgical myotomy in patients with idiopathic achalasia. N Engl J Med 381:2219–2229PubMed
45.
Wirsching A, Boshier PR, Klevebro F, Kaplan SJ, Seesing MF, El-Moslimany R, Ross A, Low DE (2019) Comparison of costs and short-term clinical outcomes of per-oral endoscopic myotomy and laparoscopic Heller myotomy. Am J Surg 218:706–711PubMed
46.
Eckardt AJ, Eckardt VF (2011) Treatment and surveillance strategies in achalasia: an update. Nat Rev Gastroenterol Hepatol 8:311–319PubMed
47.
de Heer J, Desai M, Boeckxstaens G, Zaninotto G, Fuchs KH, Sharma P, Schachschal G, Mann O, Rosch T, Werner Y (2020) Pneumatic balloon dilatation versus laparoscopic Heller myotomy for achalasia: a failed attempt at meta-analysis. Surg Endosc 35:602–611 PubMed
48.
Januszewicz W, Hartley J, Waldock W, Roberts G, Alias B, Hobson A, Wernisch L, di Pietro M (2019) Endoscopic measurement of gastric pH associates with persistent acid reflux in patients treated with proton-pump inhibitors for gastroesophageal reflux disease. United Eur Gastroenterol J 7:1389–1398
49.
Jones EL, Meara MP, Schwartz JS, Hazey JW, Perry KA (2016) Gastroesophageal reflux symptoms do not correlate with objective pH testing after peroral endoscopic myotomy. Surg Endosc 30:947–952PubMed
50.
Kumbhari V, Familiari P, Bjerregaard NC, Pioche M, Jones E, Ko WJ, Hayee B, Cali A, Ngamruengphong S, Mion F, Hernaez R, Roman S, Tieu AH, El Zein M, Ajayi T, Haji A, Cho JY, Hazey J, Perry KA, Ponchon T, Kunda R, Costamagna G, Khashab MA (2017) Gastroesophageal reflux after peroral endoscopic myotomy: a multicenter case-control study. Endoscopy 49:634–642PubMed
51.
Aiolfi A, Tornese S, Bonitta G, Cavalli M, Rausa E, Micheletto G, Campanelli G, Bona D (2020) Dor versus Toupet fundoplication after laparoscopic Heller myotomy: systematic review and Bayesian meta-analysis of randomized controlled trials. Asian J Surg 43:20–28PubMed
52.
Siddaiah-Subramanya M, Yunus RM, Khan S, Memon B, Memon MA (2019) Anterior Dor or posterior Toupet with Heller myotomy for achalasia cardia: a systematic review and meta-analysis. World J Surg 43:1563–1570PubMed
53.
Velanovich V (2007) The development of the GERD-HRQL symptom severity instrument. Dis Esophagus 20:130–134PubMed
54.
Hartling L, Featherstone R, Nuspl M, Shave K, Dryden DM, Vandermeer B (2017) Grey literature in systematic reviews: a cross-sectional study of the contribution of non-English reports, unpublished studies and dissertations to the results of meta-analyses in child-relevant reviews. BMC Med Res Methodol 17:64PubMedPubMedCentral
55.
Aiolfi A, Bona D, Riva CG, Micheletto G, Rausa E, Campanelli G, Olmo G, Bonitta G, Bonavina L (2020) Systematic review and Bayesian network meta-analysis comparing laparoscopic Heller myotomy, pneumatic dilatation, and peroral endoscopic myotomy for esophageal achalasia. J Laparoendosc Adv Surg Tech A 30:147–155PubMed
56.
Awaiz A, Yunus RM, Khan S, Memon B, Memon MA (2017) Systematic review and meta-analysis of perioperative outcomes of peroral endoscopic myotomy (POEM) and laparoscopic Heller myotomy (LHM) for achalasia. Surg Laparosc Endosc Percutan Tech 27:123–131PubMed
57.
Evensen H, Kristensen V, Larssen L, Sandstad O, Hauge T, Medhus AW (2019) Outcome of peroral endoscopic myotomy (POEM) in treatment-naive patients. A systematic review. Scand J Gastroenterol 54:1–7PubMed
58.
Martins RK, Ribeiro IB, Hourneqaux de Moura DT, Hathorn KE, Bernardo WM, Hourneaux de Mourra EG (2020) Peroral (POEM) or surgical myotomy for the treatment of achalasia: a systematic review and meta-analysis. Arq Gastroenterol 57:79–86PubMed
59.
Cappell MS, Stavropoulos SN, Friedel D (2020) Updated systematic review of achalasia, with a focus on POEM therapy. Dig Dis Sci 65:38–65PubMed
60.
Teitelbaum EN, Rajeswaran S, Zhang R, Sieberg RT, Miller FH, Soper NJ, Hungness ES (2013) Peroral esophageal myotomy (POEM) and laparoscopic Heller myotomy produce a similar short-term anatomic and functional effect. Surgery 154:885–891 (discussion 891–882)PubMed
61.
Chan SM, Wu JC, Teoh AY, Yip HC, Ng EK, Lau JY, Chiu PW (2016) Comparison of early outcomes and quality of life after laparoscopic Heller’s cardiomyotomy to peroral endoscopic myotomy for treatment of achalasia. Dig Endosc 28:27–32PubMed
Metadata
Title
Is peroral endoscopic myotomy (POEM) more effective than pneumatic dilation and Heller myotomy? A systematic review and meta-analysis
Authors
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
Publication date
01-05-2021
Publisher
Springer US
Published in
Surgical Endoscopy / Issue 5/2021
Print ISSN: 0930-2794
Electronic ISSN: 1432-2218
DOI
https://doi.org/10.1007/s00464-021-08353-w

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