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

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 scores <= 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.