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

Abstract

Background and study aims We aimed to perform an economic evaluation of peroral endoscopic myotomy (POEM) and laparoscopic Heller myotomy (LHM) for the treatment of achalasia. Materials and methods An economic cost-utility analysis was carried out over a time horizon of 1 year. Patients with achalasia who were admitted to the gastroenterology outpatient clinic of a public tertiary referral hospital were assigned to undergo POEM or LHM. The monetary amounts ​​were extracted from the intranet of the institution using microcosting. All costs associated with the procedure, hospitalization, clinical follow-up and resolution of therapeutic complications were included. The utility data were measured in quality-adjusted life years (QALYs), which were estimated from the scores of a quality-of-life questionnaire. Results Forty patients (20 POEM patients and 20 LHM patients) were included. The final cost associated with POEM and LHM was US$ 2,619.19 ± 399.53 and US$ 1,696.44 ± 412.21, respectively (P < 0.001). However, the QALYs in the POEM group (0.434 ± 0.215 vs 0.332 ± 0.222, P = 0.397) were slightly higher than those in the LHM group. The incremental cost-utility ratio (ICUR) suggested that an additional US$ 9,046.41/QALY gained was required when using POEM. Conclusion For the treatment of achalasia in the public health system, POEM appears to be more cost-effective than LHM in the short term.

Peroral endoscopic myotomy compared to laparoscopic Heller myotomy and pneumatic dilation in the treatment of achalasia: a systematic review

“…POEM is of similar efficacy to LHM in follow-up. 13–19 Comparable treatment success was observed by two RCTs 13 , 14 on analysis of 221 and 40 patients. A retrospective analysis of 98 patients observed significantly longer time to treatment failure in POEM groups compared to LHM despite no difference in Eckardt scores at 36 months.…”

Achalasia: Current therapeutic options

“…Because of this, the lower incidence of reflux and cost-effective analysis that favor PD over LHM as initial therapy for achalasia, 133,134 a case can be made for offering PD as first line therapy in type II achalasia, with either POEM or LHM used when response to PD is inadequate. Recent studies suggest that POEM is more cost-effective than LHM, [135][136][137] but currently this evidence alone is not strong enough to justify choosing POEM over LHM in the treatment of achalasia. Although the recent RCT comparing LHM to POEM 91 did not find differences in outcome in Type III achalasia, the numbers were small, and there is evidence from larger case-controlled series 59,138 that POEM is the preferred option for type III achalasia because it allows tailored proximal extension of the myotomy to deal with the spastic contractions of the esophageal body.…”

Gastroesophageal Reflux Waning Over Time in Endoscopic Versus Surgical Myotomy for the Treatment of Achalasia: A Systematic Review and Meta-Analysis

“…The initial search identified 14,540 articles, resulting in 33 systematic reviews, composed of 30 observational studies (Table 1) and three RCTs [6,46,47] (Table 2). The study by Trieu et al [41] was excluded from the meta-analysis by evaluating the same database already included in Khoraki et al [29].…”

“…The study by Trieu et al [41] was excluded from the meta-analysis by evaluating the same database already included in Khoraki et al [29]. The same occurred for the study by Conte et al [46], which was replaced by de Moura et al [47], who published updated data from the same sample. The final PRISMA flow diagram (Figure 1) resulted in 29 observational studies [42][43][44][45] and two RCTs [6,47], evaluating 3,049 patients who underwent POEM and 10,865 who underwent HMF, totaling 13,914 patients.…”

“…The initial search identified 14,540 articles, resulting in 33 systematic reviews, composed of 30 observational studies [ 16 - 45 ] (Table 1 ) and three RCTs [ 6 , 46 , 47 ] (Table 2 ).…”