Gastroesophageal Reflux Waning Over Time in Endoscopic Versus Surgical Myotomy for the Treatment of Achalasia: A Systematic Review and Meta-Analysis

Abstract

Peroral endoscopic myotomy (POEM) and Heller myotomy with fundoplication (HMF) effectively treat achalasia, an esophageal motor disease. Although a significant number of meta-analyses have compared POEM and HMF, these studies showed discrepant postoperative gastroesophageal reflux disease (GERD) conclusions. This review aimed to objectively compare GERD over time, as well as the efficiency, safety, and adverse events in POEM versus HMF for treating achalasia. We performed a systematic review and meta-analysis by searching Medline, Embase, Cochrane Library, Scopus, and Clinicaltrials.gov. The evaluated outcomes included early (within 12 months) and late (beyond 12 months) endoscopic assessment of GERD using the Lyon Consensus, clinical success, operative duration (OD), length of stay (LOS), and major adverse events (MAE). A total of 29 observational studies and two randomized clinical trials (RCTs) with 13,914 patients were included. GERD was 28% higher among RCTs discussing POEM at early assessment (95%CI 0.02, 0.54) and was not different at late evaluation (95% confidence interval (CI) = 0.00, 0.22). No difference in reflux was observed among observational studies in both periods. The clinical success was 9% higher (95% CI = 0.05, 0.12), and the OD was 37.74 minutes shorter (95% CI = -55.44, -20.04) in POEM among observational studies, whereas it was not different among RCTs. The LOS and MAE were similar in the groups. Comparisons among studies yielded divergent results. RCTs revealed that POEM had a higher incidence of GERD in the early assessment, whereas observational studies showed higher clinical success and a shorter OD in POEM. Ultimately, the between-group difference waned over time in GERD in all comparisons, resulting in no difference among RCTs in the late evaluation. Our meta-analysis demonstrated a non-preferential treatment of achalasia between endoscopic or surgical cardiomyotomy, prioritizing an individualized approach in the long term.

Keywords: esophageal achalasia; gastroesophageal reflux; heller myotomy; meta-analysis; peroral endoscopic myotomy (poem); systematic review.

Figure 1. PRISMA flow diagram showing the study selection process.

PRISMA: Preferred Reporting Items for Systematic Reviews and Meta-Analyses

Figure 2. Cochrane Risk of Bias in Non-randomized Studies of Interventions.

Studies represented in the figure [16-45].

Figure 3. Cochrane Risk of Bias Tool 2.0.

Studies represented in the figure [6,46,47].

Figure 4. Early endoscopic findings of GERD (within 12 months).

Studies represented in the forest plot: five observational studies [16,21,37,38,44] and two randomized controlled trials [6,47]. POEM: peroral endoscopic myotomy; M-H: Mantel-Haenszel; CI: confidence interval; GERD: gastroesophageal reflux disease

Figure 5. Late endoscopic findings of GERD (beyond 12 months)

Studies represented in the forest plot: two observational studies [34,36] and two randomized controlled trials [6,47] POEM: peroral endoscopic myotomy; M-H: Mantel-Haenszel; CI: confidence interval; GERD: gastroesophageal reflux disease

Figure 6. Clinical success (Eckardt symptom score ≤3).

Studies represented in the forest plot: 19 observational studies [19,21,23,25,27,28,31,32,34-40,42-45] and two randomized controlled trials [6,47]. POEM: peroral endoscopic myotomy; M-H: Mantel-Haenszel; CI: confidence interval

Figure 7. Operative duration (minutes).

Studies represented in the forest plot: 16 observational studies [16-20,23,26,30-32,34,35,38,39,42,45] and two randomized controlled trials [6,47]. POEM: peroral endoscopic myotomy; M-H: Mantel-Haenszel; CI: confidence interval

Figure 8. Length of stay (days).

Studies represented in the forest plot: 18 observational studies [17-20,22,23,26,29-36,42,43,45] and two randomized controlled trials [6,47]. POEM: peroral endoscopic myotomy; M-H: Mantel-Haenszel; CI: confidence interval

Figure 9. Major adverse events (Clavien-Dindo grades II to V).

Studies represented in the forest plot: 22 observational studies [16-21,23,24,26-32,34-38,42,45] and two randomized controlled trials [6,47]. POEM: peroral endoscopic myotomy; M-H: Mantel-Haenszel; CI: confidence interval