Efficacy and safety of full-thickness versus circular peroral endoscopic myotomy for treatment of achalasia: a systematic review and meta-analysis.

Abstract

Background: Peroral endoscopic myotomy (POEM) is a treatment for esophageal achalasia with 2 variations in myotomy depth: full-thickness myotomy (FTM) and circular myotomy (CM). This systematic review and meta-analysis compares the efficacy and safety of these variations.

Methods: Major health databases and registers, including Embase, MEDLINE and Cochrane were searched systematically. The primary outcome was clinical success, while secondary outcomes included change in achalasia severity scores, post-POEM gastroesophageal reflux disease (GERD) measures, procedural time, and adverse events. Meta-analysis was conducted using random-effects models, with risk ratios (RR) and mean differences (MD) calculated for dichotomous and continuous variables, respectively.

Results: Nine observational studies compared FTM and CM in 1,203 patients. FTM was performed in more severe achalasia and demonstrated similar clinical success to CM (RR 1.01, 95% confidence interval [CI] 0.98-1.04; P=0.55; n=6) and procedural time (MD 3.49 min, 95%CI -2.79-9.78; P=0.28, I ²=66%; n=3). FTM was associated with increased post-POEM GERD outcomes, post-POEM pain (RR 1.94, 95%CI 1.27-2.95; P=0.002; n=2), and length of stay (LOS) (MD 0.85 days, 95%CI 0.11-1.59; P=0.02; I ²=0%; n=2); however, association with esophagitis disappeared when proton pump inhibitors use was accounted for (RR 1.68, 95%CI 0.89-3.16; P=0.11; I ²=23%; n=4). CM was associated with higher rates of subcutaneous emphysema (RR 0.59, 95%CI 0.43-0.81; P=0.001; n=5).

Conclusions: FTM and CM have comparable observed clinical efficacy and procedural time, with minimal differences in complications. FTM may be preferred in more severe achalasia and its association with post-POEM GERD may have been overestimated, but it may increase post-POEM pain and LOS.