Gastroesophageal reflux disease over time in endoscopic versus surgical myotomy for treatment of achalasia: Systematic review and meta-analysis

Background and study aims Achalasia, a motor disorder of the esophagus, is treated with peroral endoscopic myotomy (POEM) or Heller myotomy with fundoplication (HMF). Although POEM lacks an antireflux mechanism, potentially increasing postoperative gastroesophageal reflux disease (GERD), limiting the endoscopic approach, this difference in GERD tends to diminish over time. The objective of this study was to compare GERD over time, the need for regular gastric acid suppression therapy (GAST), effectiveness, and safety between POEM and HMF in treating achalasia. Methods A systematic review and meta-analysis was conducted by searching mainly in MEDLINE, EMBASE, and ClinicalTrials.gov. Primary outcomes included early (< 12 months) and late (>= 12 months) evaluations of postoperative GERD based on endoscopic criteria of the Lyon Consensus 2.0, and GAST. Secondary outcomes included clinical success (Eckardt score <= 3), procedure time, length of stay, and major adverse events (AEs) (Clavien-Dindo classification >= 2) Results Thirty-two observational studies and two randomized trials were included, totaling 14,125 patients. GERD was higher in POEM in early evaluation (risk ratio [RR] = 3.03; P P < 0.01). GERD occurrence was similar between POEM and HMF in the late evaluation ( P = 0.30). Higher GAST was observed in POEM (RR = 1.35; P = 0.02). Secondly, clinical success was higher in POEM (RR = 1.06; P = 0.01), with shorter procedure time (median 39.53 minutes; P < 0.01) and shorter length of stay (mean different = -0.51 day; P = 0.03), with similar major AEs ( P = 0.81) compared with HMF. Conclusions A higher rate of early GERD is observed in POEM compared with HMF, with the difference waning over time and reaching equivalence after 12 months, despite a higher rate of GAST in the endoscopic group. POEM also exhibited effectiveness and safety comparable to the surgical approach.