Stony Brook University Hospital Internal Medicine Residency Stony Brook, NY, United States
Benjamin D. Renelus, MD1, Leslie Klyachman, MD2, Anika V. Paradkar, MD3, Daniel S. Jamorabo, MD4 1Johns Hopkins University School of Medicine, Baltimore, MD; 2Stony Brook University Hospital Internal Medicine Residency, Stony Brook, NY; 3Stony Brook University Hospital, Stony Brook, NY; 4Stony Brook University School of Medicine, Stony Brook, NY
Introduction: Achalasia treatment involves disrupting the hypertonic lower esophageal sphincter to relieve dysphagia. There are limited comparisons of first line surgical and endoscopic treatments with randomized controlled trials (RCTs). We compared the efficacy of these modalities using meta-regression and meta-analysis.
Methods: We performed a systematic review of PubMed/Medline, Embase, and Scopus databases for RCTs comparing first line endoscopic treatments—pneumatic dilation (PD) and per oral endoscopic myotomy (POEM)—with each other and with surgical myotomy (SM). Our primary endpoint was treatment success 1-2 years post therapy based upon validated scoring systems using patient-reported symptoms. Our secondary endpoint was clinical success among the various treatment modalities with achalasia type III. A meta-analytic fixed-effects generalized linear model with meta-regression was created to evaluate the proportion of endpoints achieved between the interventions compared. Odds ratios (OR) and 95% confidence intervals (CI) were calculated. Random effect modeling with pooled risk difference (RD) estimates were portrayed on Forest plots.
Results: We included 9 RCTs for analysis. POEM was used in two studies: one comparing it to PD and the other to SM. When compared to PD, SM showed a significant association with treatment success (RD 1.10; 95% CI, 1.01-1.18; p=0.03). There was no difference in treatment success between SM and POEM (OR 0.83; 95% CI, 0.50-1.36; p=0.46). SM outperformed PD for type III achalasia treatment (OR 6.74; 95% CI, 1.13-40.10; p=0.04), but there was no difference when compared to POEM (OR 0.90; 95% CI, 0.13-6.45; p=0.92).
Discussion: There are limited head to head trials comparing POEM with either PD or SM for overall achalasia management along with type III. Our study shows that SM outperforms PD, but not POEM, for achalasia therapy including type III. POEM is an effective treatment option for achalasia and is less invasive than SM. Further prospective trials comparing endoscopic and surgical myotomy among achalasia subtypes are needed to better elucidate ideal treatment options for patients.
Figure: Pneumatic Dilation versus Surgical Myotomy Forest Plot
Benjamin Renelus indicated no relevant financial relationships.
Leslie Klyachman indicated no relevant financial relationships.
Anika Paradkar indicated no relevant financial relationships.
Daniel Jamorabo indicated no relevant financial relationships.
Benjamin D. Renelus, MD1, Leslie Klyachman, MD2, Anika V. Paradkar, MD3, Daniel S. Jamorabo, MD4. P2412 - Comparison of First Line Treatments for Achalasia: A Systematic Review with Meta-Regression and Meta-Analysis, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.