Anterior versus posterior approach in peroral endoscopic myotomy (POEM): a systematic review and meta-analysis

Abstract

Background Peroral endoscopic myotomy (POEM) is increasingly being used as the endoscopic treatment option for achalasia. Data are limited as to the comparative efficacy of anterior vs. posterior myotomy. Methods We searched multiple databases from inception to August 2019 to identify studies reporting on POEM. We selected studies that reported on the outcomes of POEM, along with information on myotomy approach. We performed a comparative analysis of clinical success, gastroesophageal reflux disease (GERD), and adverse events with anterior and posterior myotomy in POEM by meta-analysis. Results 1247 patients from 18 studies were analyzed: 623 patients (11 cohorts) were treated via anterior myotomy and 624 patients (12 cohorts) via posterior myotomy. The pooled rate for clinical success gave an odds ratio (OR) of 1.02 (95 % confidence interval [CI] 0.52 – 2.0; I 2 0; P = 0.9); for GERD by esophagogastroduodenoscopy (EGD) was OR 1.02 (95 %CI 0.62 – 1.68; I 2 0; P = 0.9), and for GERD by pH was OR 0.98 (95 %CI 0.59 – 1.63; I 2 34; P = 0.9). The individual pooled rates of clinical success at 12 months and > 12 months, GERD (by symptoms, EGD, pH), and adverse events (mild, moderate, severe) were comparable. The pooled total procedure time with anterior myotomy was 82.7 minutes (95 %CI 69.0 – 96.4; I 2 98) and with posterior myotomy was 62.1 minutes (95 %CI 48.5 – 75.7; I 2 90). Conclusion Anterior and posterior myotomy in POEM seem comparable to each other in terms of clinical success, GERD, and adverse events. The total procedure time with posterior myotomy seems to be shorter than with anterior myotomy.

Outcomes of anterior versus posterior peroral endoscopic myotomy 2 years post-procedure: prospective follow-up results from a randomized clinical trial

“…Off PPI, n/N (%) ageal acid exposure in the posterior myotomy group. Two meta-analyses [5,6] have established the comparable shortterm clinical efficacy and safety of both approaches. The current study contributes comparative data between both approaches during medium-term follow-up.…”

“…In current clinical practice, myotomy orientation is largely driven by operator preference. In recent years, several studies have focused on comparing the two approaches, revealing similar efficacy [5,6] and possibly lower risk of post-POEM gastroesophageal reflux with the posterior approach [6]. However, the limitation remains the lack of longitudinal data, as all comparative studies reported outcomes with a follow-up of less than 12 months.…”

Peroral endoscopic myotomy (POEM) is more cost-effective than laparoscopic Heller myotomy in the short term for achalasia: economic evaluation from a randomized controlled trial

“…Until recently, the only options available for treatment of achalasia were pharmacological treatments, Botox, pneumatic dilation, and surgery 29 . However, technological progress and the development of minimally invasive surgery have allowed the creation of NOTES 16 17 associated with submucosal dissection 18 , and the called POEM, revolutionizing the treatment of achalasia 30 31 32 33 .…”

Management of achalasia in 2020: Per-oral endoscopic myotomy, Heller’s or dilatation?

“…All the approaches have similar efficacy with no clinically relevant difference in adverse events or incidence of GERD. [48][49][50][51][52] Muscle fibres are cut in 1-2 o'clock and 5-6 o'clock position in anterior and posterior myotomy, respectively (Fig. 3).…”