Peroral endoscopic myotomy for achalasia patients with prior Heller myotomy: a systematic review and meta-analysis.

BACKGROUND AND AIMS Heller myotomy (HM) is considered the standard surgical treatment for achalasia patients. However, approximately 10% to 20% of achalasia patients have persistent or recurrent symptoms after HM that require further therapy. Several studies have reported the outcomes of peroral endoscopic myotomy (POEM) in these patients. We performed a systematic review and meta-analysis to evaluate the efficacy and safety of POEM in achalasia patients with prior HM. METHODS An electronic literature search was conducted of PubMed, EMBASE, The Cochrane library up to Jan 31, 2020. Studies evaluating the outcomes of POEM in achalasia patients with prior HM were eligible for inclusion. The primary outcomes were the pooled rates of clinical success (defined as post-POEM Eckardt score ≤3), mean change in Eckardt score, lower esophageal sphincter (LES) pressure, and integrated relaxation pressure (IRP). The secondary outcomes were procedure-related adverse events (AEs) and incidence of postoperative gastroesophageal reflux disease (GERD). RESULTS 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. Clinical success was achieved in 90.0% (95% CI, 83.1%-96.8%) of patients. Eckardt score, LES pressure and IRP were significantly lowered by 5.14 (95% CI, 4.19-6.09), 12.01 mm Hg (95% CI, 6.74-17.27) and 10.02 mm Hg (95% CI, 4.95-15.09), respectively. The pooled rates of postoperative symptomatic reflux, esophagitis, and abnormal pH monitoring were 36.9% (95% CI, 20.7%-53.1%), 33.0% (95% CI, 9.6%-56.4%), 47.8% (95% CI, 33.4%-62.2%), respectively. Substantial heterogeneity was detected across all outcome measurements. Most of the AEs were self-limiting or managed conservatively. CONCLUSIONS POEM is a safe and effective treatment for achalasia patients with prior HM. Further data from prospective, controlled studies with long-term follow-up are needed to confirm these findings.