Peroral endoscopic myotomy (POEM) vs pneumatic dilation (PD) in treatment of achalasia: A meta-analysis of studies with ≥ 12-month follow-up

Andrew Ofosu; Babu P. Mohan; Yervant Ichkhanian; Maen Masadeh; John Febin; Mohamed Barakat; Daryl Ramai; Saurabh Chandan; Gulara Haiyeva; Shahab R. Khan; Mohamad Aghaie Meybodi; Antonio Facciorusso; Alessandro Repici; Sachin Wani; Nirav Thosani; Mouen A. Khashab

doi:10.1055/a-1483-9406

Endoscopy International Open, Table of Contents

CC BY-NC-ND 4.0 · Endosc Int Open 2021; 09(07): E1097-E1107
DOI: 10.1055/a-1483-9406

Original article

Peroral endoscopic myotomy (POEM) vs pneumatic dilation (PD) in treatment of achalasia: A meta-analysis of studies with ≥ 12-month follow-up

Andrew Ofosu‡

¹Gastroenterology and Hepatology, Stanford University, Stanford, California, United States

,

Babu P. Mohan‡

²Gastroenterology and Hepatology, University of Utah Health, Salt Lake City, Utah, United States

,

Yervant Ichkhanian

³Internal Medicine, Henry Ford University Medical Center, Detroit, Michigan, United States

,

Maen Masadeh

⁴Kaiser Permanente Northern California, California, United States

,

John Febin

¹Gastroenterology and Hepatology, Stanford University, Stanford, California, United States

,

Mohamed Barakat

¹Gastroenterology and Hepatology, Stanford University, Stanford, California, United States

,

Daryl Ramai

¹Gastroenterology and Hepatology, Stanford University, Stanford, California, United States

,

Saurabh Chandan

⁵Gastroenterology and Hepatology, University of Nebraska, United States

,

Gulara Haiyeva

⁶Beneficts Hospital Inc., Great Falls, Montana, United States

,

Shahab R. Khan

⁷Gastroenterology, Rush University Medical Center, Chicago, Illinois, United States

,

Mohamad Aghaie Meybodi

⁸Gastroenterology and Hepatology, John Hopkins University Hospital, Baltimore, Maryland, United States

,

Antonio Facciorusso

⁹Gastroenterology Unit, Department of Medical Sciences, University of Foggia, Foggia, Italy

,

Alessandro Repici

¹⁰Humanitas Research Hospital, Humanitas University, Rozzano, Milan, Italy

,

Sachin Wani

¹¹Gastroenterology, University of Colorado School of Medicine, Aurora, Colorado, United States

,

Nirav Thosani

¹²Gastroenterology, Hepatology and Nutrition, University of Texas Health Science Center at Houston, Houston, Texas, United States

,

Mouen A. Khashab

⁸Gastroenterology and Hepatology, John Hopkins University Hospital, Baltimore, Maryland, United States

› Author Affiliations

Abstract

Background and study aims Peroral endoscopic myotomy (POEM) is increasingly being used as the preferred treatment option for achalasia. The aim of this systematic review and meta-analysis was to compare the efficacy and safety of POEM versus pneumatic balloon dilation (PD).

Methods We performed a comprehensive review of studies that reported clinical outcomes of POEM and PD for the treatment of achalasia. Measured outcomes included clinical success (improvement of symptoms based on a validated scale including an Eckardt score ≤ 3), adverse events, and post-treatment gastroesophageal reflux disease (GERD).

Results Sixty-six studies (6268 patients) were included in the final analysis, of which 29 studies (2919 patients) reported on POEM and 33 studies (3050 patients) reported on PD and 4 studies (299 patients) compared POEM versus PD. Clinical success with POEM was superior to PD at 12, 24, and 36 months (92.9 %, vs 76.9 % P = 0.001; 90.6 % vs 74.8 %, P = 0.004; 88.4 % vs 72.2 %, P = 0.006, respectively). POEM was superior to PD in type I, II and III achalasia (92.7 % vs 61 %, P = 0.01; 92.3 % vs 80.3 %, P = 0.01; 92.3 %v 41.9 %, P = 0.01 respectively)

Pooled OR of clinical success at 12 and 24 months were significantly higher with POEM (8.97; P = 0.001 & 5.64; P = 0.006). Pooled OR of GERD was significantly higher with POEM (by symptoms: 2.95, P = 0.02 and by endoscopic findings: 6.98, P = 0.001). Rates of esophageal perforation (0.3 % vs 0.6 %, P = 0.8) and significant bleeding (0.4 % vs 0.7 %, P = 0.56) were comparable between POEM and PD groups.

Conclusions POEM is more efficacious than PD in the treatment of patients with achalasia during short-term and long-term follow-up, albeit with higher risk of abnormal esophageal acid exposure.

Full Text

References

References
1 Vaezi MF, Pandolfino JE, Vela MF. ACG clinical guideline: diagnosis and management of achalasia. Am J Gastroenterol 2013; 108: 1238-1249 quiz 50
2 Fisichella PM, Raz D, Palazzo F. et al. Clinical, radiological, and manometric profile in 145 patients with untreated achalasia. World J Surg 2008; 32: 1974-1979
3 Sadowski DC, Ackah F, Jiang B. et al. Achalasia: incidence, prevalence and survival. A population-based study. Neurogastroenterol Motil 2010; 22: e256-e261
4 Boeckxstaens GE, Zaninotto G, Richter JE. Achalasia. Lancet 2014; 383: 83-93
5 Cheng JW, Li Y, Xing WQ. et al. Laparoscopic Heller myotomy is not superior to pneumatic dilation in the management of primary achalasia: Conclusions of a systematic review and meta-analysis of randomized controlled trials. Medicine (Baltimore) 2017; 96: e5525
6 Inoue H, Minami H, Kobayashi Y. et al. Peroral endoscopic myotomy (POEM) for esophageal achalasia. Endoscopy 2010; 42: 265-271
7 Stavropoulos SN, Desilets DJ, Fuchs KH. et al. Per-oral endoscopic myotomy white paper summary. Gastrointest Endosc 2014; 80: 1-15
8 Moher D, Liberati A, Tetzlaff J. et al. Preferred Reporting Items for Systematic Reviews and Meta-Analyses: The PRISMA Statement. Ann Int Med 2009; 151: 264-269
9 Stroup DF, Berlin JA, Morton SC. et al. Meta-analysis of observational studies in epidemiology: a proposal for reporting. Meta-analysis Of Observational Studies in Epidemiology (MOOSE) group. JAMA 2000; 283: 2008-2012
10 Stang A. Critical evaluation of the Newcastle-Ottawa scale for the assessment of the quality of nonrandomized studies in meta-analyses. Eur J Epidemiol 2010; 25: 603-605
11 Cotton PB, Eisen GM, Aabakken L. et al. A lexicon for endoscopic adverse events: report of an ASGE workshop. Gastrointest Endosc 2010; 71: 446-454
12 Glenny AM, Altman DG, Song F. et al. Indirect comparisons of competing interventions. Health Technol Assess 2005; 9: 1-134
13 DerSimonian R, Laird N. Meta-analysis in clinical trials. Control Clin Trials 1986; 7: 177-188
14 Sutton AJ, Jones DR. et al. Methods for Meta-Analysis in Medical Research. Wiley; 2000: 348
15 Higgins JP, Thompson SG, Spiegelhalter DJ. A re-evaluation of random-effects meta-analysis. J R Stat Soc Ser A Stat Soc 2009; 172: 137-159
16 Riley RD, Higgins JP, Deeks JJ. Interpretation of random effects meta-analyses. BMJ 2011; 342-549
17 Mohan BP, Adler DG. Heterogeneity in systematic review and meta-analysis: how to read between the numbers. Gastrointest Endosc 2019; 89: 902-903
18 Kanwal F, White D. “Systematic Reviews and Meta-analyses” in Clinical Gastroenterology and Hepatology. Clin Gastroenterol Hepatol 2012; 10: 1184-1186
19 Higgins JP, Thompson SG, Deeks JJ. et al. Measuring inconsistency in meta-analyses. BMJ 2003; 327: 557-560
20 Guyatt GH, Oxman AD, Kunz R. et al. GRADE guidelines: 7. Rating the quality of evidence--inconsistency. J Clin Epidemiol 2011; 64: 1294-1302
21 Easterbrook PJ, Berlin JA, Gopalan R. et al. Publication bias in clinical research. Lancet 1991; 337: 867-872
22 Duval S, Tweedie R. Trim and fill: A simple funnel-plot-based method of testing and adjusting for publication bias in meta-analysis. Biometrics 2000; 56: 455-463
23 Borenstein M. Publication Bias in Meta-Analysis: Prevention, Assessment and Adjustments. Rothstein HR. Wiley; 2005: 376
24 de Pascale S, Repici A, Puccetti F. et al. Peroral endoscopic myotomy versus surgical myotomy for primary achalasia: single-center, retrospective analysis of 74 patients. Dis Esophagus 2017; 30: 1-7
25 Gulati S, Emmanuel A, Inoue H. et al. Peroral endoscopic myotomy: a literature review and the first UK case series. Clin Med (Lond) 2017; 17: 22-28
26 Guo H, Yang H, Zhang X. et al. Long-term outcomes of peroral endoscopic myotomy for patients with achalasia: a retrospective single-center study. Dis Esophagus 2017; 30: 1-6
27 Hungness ES, Sternbach JM, Teitelbaum EN. et al. Per-oral endoscopic myotomy (POEM) after the learning curve: durable long-term results with a low complication rate. Ann Surg 2016; 264: 508-517
28 Inoue H, Sato H, Ikeda H. et al. Per-oral endoscopic myotomy: a series of 500 patients. J Am Coll Surg 2015; 221: 256-264
29 Kumagai K, Tsai JA, Thorell A. et al. Per-oral endoscopic myotomy for achalasia. Are results comparable to laparoscopic Heller myotomy? . Scand J Gastroenterol 2015; 50: 505-512
30 Louie BE, Schneider AM, Schembre DB. et al. Impact of prior interventions on outcomes during per oral endoscopic myotomy. Surg Endosc 2017; 31: 1841-1848
31 Lv L, Liu J, Tan Y. et al. Peroral endoscopic full-thickness myotomy for the treatment of sigmoid-type achalasia: outcomes with a minimum follow-up of 12 months. Eur J Gastroenterol Hepatol 2016; 28: 30-36
32 Meng F, Li P, Wang Y. et al. Peroral endoscopic myotomy compared with pneumatic dilation for newly diagnosed achalasia. Surg Endosc 2017; 31: 4665-4672
33 Patel KS, Calixte R, Modayil RJ. et al. The light at the end of the tunnel: a single-operator learning curve analysis for per oral endoscopic myotomy. Gastrointest Endosc 2015; 81: 1181-1187
34 Peng L, Tian S, Du C. et al. Outcome of peroral endoscopic myotomy (POEM) for treating achalasia compared with laparoscopic heller myotomy (LHM). Surg Laparosc Endosc Percutan Tech 2017; 27: 60-64
35 Ponds FA, Fockens P, Lei A. et al. 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 2019; 322: 134-144
36 Wang X, Tan Y, Lv L. et al. Peroral endoscopic myotomy versus pneumatic dilation for achalasia in patients aged ≥ 65 years. Rev Esp Enferm Dig 2016; 108: 637-641
37 Ward MA, Gitelis M, Patel L. et al. Outcomes in patients with over 1-year follow-up after peroral endoscopic myotomy (POEM). Surg Endosc 2017; 31: 1550-1557
38 Zheng Z, Zhao C, Su S. et al. Peroral endoscopic myotomy versus pneumatic dilation – result from a retrospective study with 1-year follow-up. Z Gastroenterol 2019; 57: 304-311
39 Ramchandani M, Nageshwar Reddy D, Darisetty S. et al. Peroral endoscopic myotomy for achalasia cardia: Treatment analysis and follow up of over 200 consecutive patients at a single center. Dig Endosc 2016; 28: 19-26
40 Ngamruengphong S, Inoue H, Ujiki MB. et al. Efficacy and safety of peroral endoscopic myotomy for treatment of achalasia after failed Heller myotomy. Clin Gastroenterol Hepatol 2017; 15: 1531-1537
41 Sharata AM, Dunst CM, Pescarus R. et al. Peroral endoscopic myotomy (POEM) for esophageal primary motility disorders: analysis of 100 consecutive patients. J Gastrointest Surg 2015; 19: 161-170 discussion 70
42 Duan T, Tan Y, Zhou J. et al. A retrospective study of peroral endoscopic full-thickness myotomy in patients with severe achalasia. J Laparoendosc Adv Surg Tech A 2017; 27: 770-776
43 Tang X, Gong W, Deng Z. et al. Feasibility and safety of peroral endoscopic myotomy for achalasia after failed endoscopic interventions. Dis Esophagus 2017; 30: 1-6
44 Tang X, Ren Y, Gao Q. et al. Peroral endoscopic myotomy is safe and effective in achalasia patients aged older than 60 years compared with younger patients. Geriatr Gerontol Int 2017; 17: 2407-2413
45 Zhang X, Modayil RJ, Friedel D. et al. Per-oral endoscopic myotomy in patients with or without prior Hellerʼs myotomy: comparing long-term outcomes in a large U.S. single-center cohort (with videos). Gastrointest Endosc 2018; 87: 972-985
46 Alderliesten J, Conchillo JM, Leeuwenburgh I. et al. Predictors for outcome of failure of balloon dilatation in patients with achalasia. Gut 2011; 60: 10-16
47 Aljebreen AM, Samarkandi S, Al-Harbi T. et al. Efficacy of pneumatic dilatation in Saudi achalasia patients. Saudi J Gastroenterol 2014; 20: 43-47
48 Andreevski V, Nojkov B, Krstevski M. et al. Short and medium-term therapeutic effects of pneumatic dilatation for achalasia: a 15-year tertiary centre experience. Pril (Makedon Akad Nauk Umet Odd Med Nauki) 2013; 34: 15-22
49 Borges AA, Lemme EM, Abrahao LJ. et al. Pneumatic dilation versus laparoscopic Heller myotomy for the treatment of achalasia: variables related to a good response. Dis Esophagus 2014; 27: 18-23
50 Bravi I, Nicita MT, Duca P. et al. A pneumatic dilation strategy in achalasia: prospective outcome and effects on oesophageal motor function in the long term. Aliment Pharmacol Ther 2010; 31: 658-665
51 Chen X, Li QP, Ji GZ. et al. Two-year follow-up for 45 patients with achalasia who underwent peroral endoscopic myotomy. Eur J Cardiothorac Surg 2015; 47: 890-896
52 Chuah SK, Hu TH, Wu KL. et al. Clinical remission in endoscope-guided pneumatic dilation for the treatment of esophageal achalasia: 7-year follow-up results of a prospective investigation. J Gastrointest Surg 2009; 13: 862-867
53 Dagli U, Kuran S, Savas N. et al. Factors predicting outcome of balloon dilatation in achalasia. Dig Dis Sci 2009; 54: 1237-1242
54 Dobrucali A, Erzin Y, Tuncer M. et al. Long-term results of graded pneumatic dilatation under endoscopic guidance in patients with primary esophageal achalasia. World J Gastroenterol 2004; 10: 3322-3327
55 Doder R, Perisic N, Tomasevic R. et al. Long-term outcome of a modified balloon dilatation in the treatment of patients with achalasia. Vojnosanit Pregl 2013; 70: 915-922
56 Elliott TR, Wu PI, Fuentealba S. et al. Long-term outcome following pneumatic dilatation as initial therapy for idiopathic achalasia: an 18-year single-centre experience. Aliment Pharmacol Ther 2013; 37: 1210-1219
57 Ghoshal UC, Rangan M, Misra A. Pneumatic dilation for achalasia cardia: reduction in lower esophageal sphincter pressure in assessing response and factors associated with recurrence during long-term follow up. Dig Endosc 2012; 24: 7-15
58 Hamdy E, El Nakeeb A, El Hanfy E. et al. Comparative study between laparoscopic heller myotomy versus pneumatic dilatation for treatment of early achalasia: a prospective randomized study. J Laparoendosc Adv Surg Tech A 2015; 25: 460-464
59 Hassan MK, Khattak MA, Bakhtiar S. et al. Long term results of single session of pneumatic dilatation with 30 MM balloon for achalasia cardia. J Postgrad Med Instit (Peshawar-Pakistan) 2017; 31
60 Howard JM, Mongan AM, Manning BJ. et al. Outcomes in achalasia from a surgical unit where pneumatic dilatation is first-line therapy. Dis Esophagus 2010; 23: 465-472
61 Hulselmans M, Vanuytsel T, Degreef T. et al. Long-term outcome of pneumatic dilation in the treatment of achalasia. Clin Gastroenterol Hepatol 2010; 8: 30-35
62 Karamanolis G, Sgouros S, Karatzias G. et al. Long-term outcome of pneumatic dilation in the treatment of achalasia. Am J Gastroenterol 2005; 100: 270-274
63 Khashab MA, Kumbhari V, Tieu AH. et al. Peroral endoscopic myotomy achieves similar clinical response but incurs lesser charges compared to robotic heller myotomy. Saudi J Gastroenterol 2017; 23: 91
64 Li SW, Tseng PH, Chen CC. et al. Muscular thickness of lower esophageal sphincter and therapeutic outcomes in achalasia: A prospective study using high-frequency endoscopic ultrasound. J Gastroenterol Hepatol 2018; 33: 240-248
65 Ling TS, Guo HM, Yang T. et al. Effectiveness of peroral endoscopic myotomy in the treatment of achalasia: a pilot trial in Chinese Han population with a minimum of one-year follow-up. J Dig Dis 2014; 15: 352-358
66 Maris T, Kapetanos D, Ilias A. et al. Mid term results of pneumatic balloon dilatation in patients with achalasia. Ann Gastroenterol 2010; 61-63
67 Mikaeli J, Bishehsari F, Montazeri G. et al. Injection of botulinum toxin before pneumatic dilatation in achalasia treatment: a randomized-controlled trial. Aliment Pharmacol Ther 2006; 24: 983-989
68 Moonen A, Annese V, Belmans A. et al. Long-term results of the European achalasia trial: a multicentre randomised controlled trial comparing pneumatic dilation versus laparoscopic Heller myotomy. Gut 2016; 65: 732-739
69 Novais PA, Lemme EM. 24-h pH monitoring patterns and clinical response after achalasia treatment with pneumatic dilation or laparoscopic Heller myotomy. Aliment Pharmacol Ther 2010; 32: 1257-1265
70 Park JH, Lee YC, Lee H. et al. Residual lower esophageal sphincter pressure as a prognostic factor in the pneumatic balloon treatment of achalasia. J Gastroenterol Hepatol 2015; 30: 59-63
71 Persson J, Johnsson E, Kostic S. et al. Treatment of achalasia with laparoscopic myotomy or pneumatic dilatation: long-term results of a prospective, randomized study. World J Surg 2015; 39: 713-720
72 Sabharwal T, Cowling M, Dussek J. et al. Balloon dilation for achalasia of the cardia: experience in 76 patients. Radiology 2002; 224: 719-724
73 Schneider AM, Louie BE, Warren HF. et al. A matched comparison of per oral endoscopic myotomy to laparoscopic Heller myotomy in the treatment of achalasia. J Gastrointest Surg 2016; 20: 1789-1796
74 Shejal AH, Ramachandran TM, Kumar S. Clinical outcome of pneumatic dilatation in patients with achalasia cardia: A single-center prospective study. J Digest Endosc 2017; 8: 182-186
75 Spiliopoulos S, Sabharwal T, Inchingolo R. et al. Fluoroscopically guided balloon dilatation for the treatment of achalasia: long-term outcomes. Dis Esophagus 2013; 26: 213-218
76 Tanaka Y, Iwakiri K, Kawami N. et al. Predictors of a better outcome of pneumatic dilatation in patients with primary achalasia. J Gastroenterol 2010; 45: 153-158
77 Teitelbaum EN, Soper NJ, Santos BF. et al. Symptomatic and physiologic outcomes one year after peroral esophageal myotomy (POEM) for treatment of achalasia. Surg Endosc 2014; 28: 3359-3365
78 von Renteln D, Fuchs KH, Fockens P. et al. Peroral endoscopic myotomy for the treatment of achalasia: an international prospective multicenter study. Gastroenterology 2013; 145: 309-11.e1-3
79 Werner YB, von Renteln D, Noder T. et al. Early adverse events of per-oral endoscopic myotomy. Gastrointest Endosc 2017; 85: 708-18.e2
80 Worrell SG, Alicuben ET, Boys J. et al. Peroral endoscopic myotomy for achalasia in a thoracic surgical practice. Ann Thorac Surg 2016; 101: 218-24 ; discussion 24–25
81 Yamashita H, Ashida K, Fukuchi T. et al. Predictive factors associated with the success of pneumatic dilatation in Japanese patients with primary achalasia: a study using high-resolution manometry. Digestion 2013; 87: 23-28
82 Zerbib F, Thetiot V, Richy F. et al. Repeated pneumatic dilations as long-term maintenance therapy for esophageal achalasia. Am J Gastroenterol 2006; 101: 692-697
83 Kim WH, Cho JY, Ko WJ. et al. Comparison of the outcomes of peroral endoscopic myotomy for achalasia according to manometric subtype. Gut Liver 2017; 11: 642-647
84 Lee JY, Kim N, Kim SE. et al. Clinical characteristics and treatment outcomes of 3 subtypes of achalasia according to the Chicago classification in a tertiary institute in Korea. J Neurogastroenterol Motil 2013; 19: 485-494
85 Martinek J, Svecova H, Vackova Z. et al. Per-oral endoscopic myotomy (POEM): mid-term efficacy and safety. Surg Endosc 2018; 32: 1293-1302
86 Muller M, Keck C, Eckardt AJ. et al. Outcomes of pneumatic dilation in achalasia: Extended follow-up of more than 25 years with a focus on manometric subtypes. J Gastroenterol Hepatol 2018; 33: 1067-1074
87 Nabi Z, Ramchandani M, Chavan R. et al. Peroral endoscopic myotomy in treatment-naive achalasia patients versus prior treatment failure cases. Endoscopy 2018; 50: 358-370
88 Pandolfino JE, Kwiatek MA, Nealis T. et al. Achalasia: a new clinically relevant classification by high-resolution manometry. Gastroenterology 2008; 135: 1526-1533
89 Rohof WO, Salvador R, Annese V. et al. Outcomes of treatment for achalasia depend on manometric subtype. Gastroenterology 2013; 144: 718-725 quiz e13-4
90 Ghoshal UC, Rangan M. A review of factors predicting outcome of pneumatic dilation in patients with achalasia cardia. J Neurogastroenterol Motil 2011; 17: 9-13
91 Zhang WG, Linghu EQ, Chai NL. et al. Ling classification describes endoscopic progressive process of achalasia and successful peroral endoscopy myotomy prevents endoscopic progression of achalasia. World J Gastroenterol 2017; 23: 3309-3314
92 Kim WH, Cho JY, Ko WJ. et al. Comparison of the outcomes of peroral endoscopic myotomy for achalasia according to manometric subtype. Gut Liver 2017; 11: 642-647
93 Kahrilas PJ, Katzka D, Richter JE. Clinical practice update: the use of per-oral endoscopic myotomy in achalasia: expert review and best practice advice from the AGA Institute. Gastroenterology 2017; 153: 1205-1211
94 Tyberg A, Choi A, Gaidhane M. et al. Transoral Incisionless fundoplication for reflux after peroral endoscopic myotomy: a crucial addition to our arsenal. Endosc Int Open 2018; 6: E549-E552

Supplementary Material

Supplementary material