Sa1282 PERORAL ENDOSCOPIC MYOTOMY FOR ACHALASIA PATIENTS WITH PRIOR HELLER MYOTOMY: A SYSTEMATIC REIVEW AND META-ANALYSIS

Abstract

Heller myotomy (HM) is considered the standard surgical treatment for achalasia patients. However, approximately 10-20% of achalasia patients after HM have persistent or recurrent symptoms requiring further therapy. Several studies have reported the outcomes of peroral endoscopic myotomy (POEM) in these patients. Objective: A systematic review and meta-analysis were performed to evaluate the efficacy and safety of POEM in achalasia patients with prior HM. The databases of PubMed, EMBASE, The Cochrane library were systematically searched. Studies evaluating the outcomes of POEM in achalasia patients with prior HM were eligible for inclusion. Two reviewers independently reviewed the studies, extracted data and assessed study quality. Heterogeneity among studies was assessed using the I2 statistic. Pooled estimates were calculated using random or fixed-effects models, according to the level of heterogeneity. A total of 9 studies with 272 achalasia patients were recruited in this review. POEM was successfully performed in 270 (99.3%) patients after prior HM. There was a significant reduction in Eckardt score by 5.14 (weighted mean differences (WMD) 5.14, 95%CI, 4.19-6.09, P< 0.001, I2=86.4%). Clinical success (post-POEM Eckardt score≤3) was achieved in 90% (95%CI, 83%-98%, I2=58.5%) of patients after POEM. Lower esophageal sphincter (LES) pressure was significantly lowered by 12.01 mmHg (WMD 12.01, 95%CI, 6.74–17.27, P< 0.001, I2 = 85.1%). The pooled rates of postoperative symptomatic gastroesophageal reflux, esophagitis based on after-POEM endoscopy, and abnormal acid exposure at pH monitoring were 37% (95% CI, 21%-53%), 33% (95% CI, 10%-56%), 48% (95%CI, 33%-62%), respectively. Most of the adverse effects related to POEM procedure were self-limiting and could be managed conservatively. No publication bias was found using Egger's test. POEM is a safe and effective treatment for achalasia patients with prior HM. Further data from large randomized controlled trials are needed to confirm these findings.