Comparative efficacy of first-line therapeutic interventions for achalasia: a systematic review and network meta-analysis

Abstract

Background Several interventions with variable efficacy are available as first-line therapy for patients with achalasia. We assessed the comparative efficacy of different strategies for management of achalasia, through a network meta-analysis combining direct and indirect treatment comparisons. Methods We identified six randomized controlled trials in adults with achalasia that compared the efficacy of pneumatic dilation (PD; n = 260), laparoscopic Heller myotomy (LHM; n = 309), and peroral endoscopic myotomy (POEM; n = 176). Primary efficacy outcome was 1-year treatment success (patient-reported improvement in symptoms based on validated scores); secondary efficacy outcomes were 2-year treatment success and physiologic improvement; safety outcomes were risk of gastroesophageal reflux disease (GERD), severe erosive esophagitis, and procedure-related serious adverse events. We performed pairwise and network meta-analysis for all treatments, and used GRADE criteria to appraise quality of evidence. Results Low-quality evidence, based primarily on direct evidence, supports the use of POEM (RR [risk ratio], 1.

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“…Sanaka et al [29], compared geriatric (> 65 years) vs non-geriatrics (< 65 years) retrospectively, and they found no differences in success at 2 months (94.9 % vs 94.7 %; P = NS), and similar AE (10.1 % vs 3.8 %; P = 0.42), confirming good safety and efficacy. Chen et al [31], in an international multicenter retrospective study, evaluated 76 octogenarian patients and found at mid-term (265 days), a 93.4 % of clinical success, but up to 14.5 % AE, of whom 7.1 % were severe, confirming, that in spite of POEM being safe and effective in younger patients, serious AE could be presented in octogenarian population, being higher in LHM (AE = 3 %-19 %) for these patients [8][9][10]. Low-grade esophagitis was defined as grade A or B according to LA classification system [35] and it was presented in 4.7 % to 11.2 % of our patients during follow-up.…”

“…Second, BSP is performed in a conventional fluoroscopy ▶ Table 1 Characteristics of patients and procedures. and endoscopy suite, only deep sedation is needed, there is easy placement, and no removal is needed [18,[20][21][22], representing a promising alternative in octogenarian patients with a high-risk nature (comorbidity, esophageal mucosal fragility, and anatomic esophageal changes due to aging) [1,8,10,17]. Diameter use was based on previous studies with SEMS.…”

“…Laparoscopic Heller Myotomy (LHM) and Peroral endoscopic myotomy (POEM) are considered the gold standard of treatment [4][5][6]; however, safety is compromised in some populations, such as in elderly patients (adverse events of 2 % to 11.5 % in LHM and 5 % to 7.8 % for POEM [7][8][9]), representing high-risk procedures for them. Alternative treatments include pneumatic dilation (PD) (73 %-88 % early and mid-term efficacy, but a median of 1.9 % perforation rate [4][5][6][7][8][9][10]) and botulinum toxin injection (BTI) (initial 87 % to 92 %, but 22 % to 31 % mid-term efficacy Safety and efficacy of biodegradable stents in octogenarian patients with esophageal achalasia…”

Safety and efficacy of biodegradable stents in octogenarian patients with esophageal achalasia

“…Therefore, we considered the use of BSP, based on two reasons: first, because of its safety and efficacy observed in other gastrointestinal diseases, such as BES and small bowel strictures 17 . Second, BSP is performed in a conventional fluoroscopy and endoscopy suite, only deep sedation is needed, there is easy placement, and no removal is needed 18 20 21 22 , representing a promising alternative in octogenarian patients with a high-risk nature (comorbidity, esophageal mucosal fragility, and anatomic esophageal changes due to aging) 1 8 10 17 . Diameter use was based on previous studies with SEMS.…”

“…Laparoscopic Heller Myotomy (LHM) and Peroral endoscopic myotomy (POEM) are considered the gold standard of treatment 4 5 6 ; however, safety is compromised in some populations, such as in elderly patients (adverse events of 2 % to 11.5 % in LHM and 5 % to 7.8 % for POEM 7 8 9 ), representing high-risk procedures for them. Alternative treatments include pneumatic dilation (PD) (73 %–88 % early and mid-term efficacy, but a median of 1.9 % perforation rate 4 5 6 7 8 9 10 ) and botulinum toxin injection (BTI) (initial 87 % to 92 %, but 22 % to 31 % mid-term efficacy 8 11 ). Fully or partially covered self-expandable metal stents (SEMS) have been used with variable clinical remission rates (88 % to 100 % at early-term and 49 % to 91 % at long-term 12 13 ), but with concerning adverse events (AEs) (thoracic pain 35 % to 44 %, reflux symptoms 28 % to 36 %, migration 8.5 % to 18 %, and bleeding 8 % to 12 % 14 15 16 ).…”